ENS 57165
ENS Event | |
|---|---|
04:00 May 27, 2024 | |
| Title | Brachytherapy Misadministration |
| Event Description | The following information was provided by the South Carolina Department of Health and Environmental Control via phone and email:
The South Carolina Department of Health and Environmental Control was notified on June 5, 2024, at 1130 EDT via telephone that a medical event had occurred at Medical University Hospital Authority d/b/a Medical University of South Carolina (licensee). The licensee reported that a patient had undergone a manual brachytherapy procedure (Gammatile Implantation) resulting in the implantation of forty (40) Cs-131 seeds in the patient's brain on May 16, 2024. The licensee reported that the patient had been released and then returned on May 27, 2024, due to medical complications. Seven (7) of the forty (40) Cs-131 seeds were removed from the patient on May 27, 2024, and the remaining thirty three (33) seeds were removed from the patient on May 30, 2024. The licensee is reporting that the total source strength administered differed by 20 percent or more from the total source strength documented in the post-implantation portion of the written directive. SC Event Number: 240003
The following information was provided by the South Carolina Department of Health and Environmental Control via email: For the medical event, the licensee is reporting that the total source strength documented in the post-implantation portion of the written directive is 5.54 millicuries per seed, and 221.6 millicuries total (forty seeds implanted). At the conclusion of the initial procedure on May 16, 2024, the licensee is reporting that all seeds as documented in the post-implantation portion of the written directive were administered. As of May 30, 2024, all seeds had been removed from the patient due to medical complications. Notified R1DO (Bickett), NMSS Events Notification (email).
The following information was provided by the South Carolina Department of Health and Environmental Control via email: On June 20, 2024, the licensee submitted a 15-day written report regarding the medical event. Department inspectors conducted an on-site visit between July 24 and July 31, 2024. Interviews with the licensee's representatives were consistent with the details outlined in the written report. The licensee has provided additional training to neurosurgery department staff. The investigation is considered closed. Notified R1DO (Ford), NMSS Events Notification (email) 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 | |
|---|---|
| Medical University - South Carolina Charleston, South Carolina (NRC Region 1) | |
| License number: | SC-RML-081 |
| Organization: | Sc Dept Of Health & Env Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+244.42 h10.184 days <br />1.455 weeks <br />0.335 months <br />) | |
| Opened: | Adam Gause 08:25 Jun 6, 2024 |
| NRC Officer: | Adam Koziol |
| Last Updated: | Aug 13, 2024 |
| 57165 - NRC Website | |
Medical University - South Carolina with Agreement State | |
WEEKMONTHYEARENS 571662024-05-27T04:00:00027 May 2024 04:00:00
[Table view]Agreement State Lost Brachytherapy Seeds ENS 571652024-05-27T04:00:00027 May 2024 04:00:00 Agreement State Brachytherapy Misadministration 2024-05-27T04:00:00 | |