ENS 54685

v t e ENS Event
07:00 Apr 29, 2020
Title	Agreement State Report - Medical Underdose During Brachytherapy Treatment
Event Description	The following information was received from the state of Nevada via email: The patient was undergoing radiation treatment using Ir-192 and the high dose rate remote afterloader (Varian VS 2000) in three fractions. There were no problems with fractions one and two. During the third fraction, the vaginal cylinder device was inserted into the patient by the doctor. Unknown to the doctor, the device penetrated through the body wall weakened by previous surgery (according to the doctor, [this is] not unknown following robotic hysterectomies). This penetration allowed the source to move about 4 cm past the treatment area. As a result, the treatment area only received 25 percent volume coverage instead of the planned 95 percent volume coverage. The device was a Varian Remote Afterloader, Model VS 2000, which contained 407 GBq of Ir-192. NMED Report No: NV200007 A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

ENS 54685 +/-
Where
Nv Div Of Rad Health Reno, Nevada (NRC Region 4)
License number:	16-12-0016-01
Organization:	Nv Div Of Rad Health
Reporting

Agreement State
Time - Person (Reporting Time:+35.85 h1.494 days <br />0.213 weeks <br />0.0491 months <br />)
Opened:	Corey Crevling 18:51 Apr 30, 2020
NRC Officer:	Howie Crouch
Last Updated:	Apr 30, 2020
54685 - NRC Website
v • d • e

v t e Emergency Notification System
Nv Div Of Rad Health with Agreement State
WEEKMONTHYEAR2020-04-29T07:00:00 [Table view]
[ENS list for Nv Div Of Rad Health]

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