ENS 55640

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v t e ENS Event
05:00 Oct 28, 2021
Title	Dose to Unintended Organ
Event Description	The following was received from the Commonwealth of Pennsylvania by email: On December 10, 2021, the Radiation Safety Officer for the licensee verbally reported a patient being treated for vaginal cancer was prescribed a 21 Gy total dose, to be delivered in 3 fractions of 7 Gy each via HDR [(high dose rate)]. The first fraction was delivered on October 28, 2021. At some point after that treatment, the patient began experiencing complications from the hysterectomy and ended up going to a different hospital for that issue. The patient did not return to the licensee's facility to complete her treatment. At the other hospital, a different Radiation Oncologist was consulted and was reviewing the patient's treatment and discovered that the treatment in October at the licensee was 3 cm off and the intestine received some fraction of the first treatment dose. It was discovered that the patient required re-suturing of the cervix and that the brachytherapy apparatus (used in the HDR treatment) passed beyond the apex of the vagina. This discovery was made yesterday, December 9, 2021. The licensee's medical physicist is currently calculating dose estimates. The referring physician is also being informed. No further information is available at this time. The Department of Environmental Protection will update this event as soon as more information is provided. PA Event Report ID No: PA210021 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 55640 +/-
Where
Upmc Passavant Pittsburgh, Pennsylvania (NRC Region 1)
License number:	PA-0310
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+1039.45 h43.31 days <br />6.187 weeks <br />1.424 months <br />)
Opened:	John S. Chippo 13:27 Dec 10, 2021
NRC Officer:	Lloyd Desotell
Last Updated:	Dec 10, 2021
55640 - NRC Website
v • d • e

v t e Emergency Notification System
Upmc Passavant with Agreement State
WEEKMONTHYEAR2021-10-28T05:00:00 [Table view]
[ENS list for Upmc Passavant]

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