ENS Event | |
|---|---|
05:00 May 6, 2022 | |
| Title | Three Medical Events - Underdoses |
| Event Description | The following information was provided by the Texas Department of State Health Services (the Agency) via email:
On May 6, 2022, the Agency was notified by the licensee's Radiation Safety Officer (RSO) that they had discovered that multiple medical events had occurred at their facility. The licensee had discovered on Tuesday, May 3, 2022, the needle used on a high dose rate unit (HDR) was shorter than what they thought. This resulted in underdoses to the intended tissue. The licensee has identified three cases that resulted in underdoses of 92 percent, 95 percent, and 67 percent for a single fraction on three patients. The three events occurred between November 2020, and February 2021. The RSO stated they were notifying the prescribing physicians and patients involved. They are continuing to review previous cases to determine if any additional patients were involved. The licensee will notify the appropriate individuals as the events are discovered. The RSO did not know how many patients may be involved. The source was an iridium-192 source and the activity would vary depending on the date the treatment occurred. The RSO stated that due to the needle being shorter than believed, other tissue may have been exposed to higher-than expected dose and in some events the source may have never entered the patient. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9931 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. |
| Where | |
|---|---|
| The University Of Texas Md Anderson Cancer Center Houston, Texas (NRC Region 4) | |
| License number: | 00 00466 |
| Organization: | Texas Dept Of State Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+12.13 h0.505 days <br />0.0722 weeks <br />0.0166 months <br />) | |
| Opened: | Art Tucker 17:08 May 6, 2022 |
| NRC Officer: | Jeffrey Whited |
| Last Updated: | May 6, 2022 |
| 55886 - NRC Website | |
The University Of Texas Md Anderson Cancer Center with Agreement State | |
WEEKMONTHYEARENS 558862022-05-06T05:00:0006 May 2022 05:00:00
[Table view]Agreement State Three Medical Events - Underdoses ENS 554412021-07-12T05:00:00012 July 2021 05:00:00 Agreement State Agreement State - Incorrect Radiopharmaceutical Administered ENS 508622015-03-03T22:01:0003 March 2015 22:01:00 Agreement State Agreement State Report - Irradiator Source Would Not Fully Lower to Shielded Position 2022-05-06T05:00:00 | |