ENS Event | |
|---|---|
04:00 Oct 5, 2023 | |
| Title | Agreement State - Greater than Anticipated Dose to NON-TARGET Organ |
| Event Description | The following information was provided by the New Hampshire Radiological Health Section (NHRHS) via email:
Via telephone on October 9, 2023, the licensee's Radiation Safety Officer reported a medical event associated with use of their Varian BRAVOS high dose rate remote afterloader (HDR). During a treatment fraction administered on October 5, 2023, a patient received a dose of 435 centigray (cGy) (435 rad) versus a planned dose of 700 cGy (700 rad) to the target organ (the cervix) and an estimated 586 cGy (586 rad) versus an expected 300 cGy (300 rad) to the rectum (a non-targeted organ). The dose to the non-target organ exceeds 50 percent of the expected value had the procedure been given in accordance with the written directive. The preliminary findings indicate the wrong HDR channel had been selected. The patient and physician were notified. No health effects are anticipated as a consequence of this event. When the treatment fractions are completed, the target organ will have received a dose within 20 percent of the written directive. The patient and the patient's physician were advised. No negative health effects are anticipated. Treatment fractions will continue to ensure the desired dose to the target area will be provided. The investigation, with possible identification of further corrective actions, is ongoing. More information is anticipated within 15 days. Medical Event: Exposure to a non-target organ exceeding 50 percent of anticipated during a fractional treatment. Dose intended to target organ planned / actual: 700 cGy (700 rad) / 435 cGy (435 rad); 62 percent of planned. Dose to non-target organ anticipated / actual: 300 cGy (300 rad) / 586 cGy (586 rad); 95 percent greater than anticipated. NMED Report Number: NH-23-0002 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 | |
|---|---|
| Mary Hitchcock Memorial Hospital Lebanon, New Hampshire (NRC Region 1) | |
| License number: | 130R |
| Organization: | Nh Dept Of Health & Human Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+106.53 h4.439 days <br />0.634 weeks <br />0.146 months <br />) | |
| Opened: | David Scalise 14:32 Oct 9, 2023 |
| NRC Officer: | Lawrence Criscione |
| Last Updated: | Oct 9, 2023 |
| 56782 - NRC Website | |
Mary Hitchcock Memorial Hospital with Agreement State | |
WEEKMONTHYEARENS 567822023-10-05T04:00:0005 October 2023 04:00:00
[Table view]Agreement State Agreement State - Greater than Anticipated Dose to NON-TARGET Organ ENS 524472016-11-23T05:00:00023 November 2016 05:00:00 Agreement State Agreement State Report - Medical Event Involving High Dose Rate Therapy Dose to an Unintended Location ENS 424402006-03-03T05:00:0003 March 2006 05:00:00 Agreement State Agreement State Report - Medical Event Involving the Wrong Radiopharmaceutical 2023-10-05T04:00:00 | |