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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 51745 | 27 August 2015 05:00:00 | Agreement State | Agreement State Report - Medical Overdose | The following was received via email: On August 27th 2015, a patient with 21st (Century) Oncology who was prescribed a 67.13 mCi dose of Sm-153 received an 86.9 mCi dose. The resulting over dose was more than 29.5 (percent) of the prescribed dose. The error was discovered through discrepancies in their pharmacies inventory when a new order was created for a new patient. On Feb 15, 2016, (21st Century Oncology) were preparing an order for Sm-153 for a new patient. The nurse referred to the last administered Samarium case (August 27, 2015) for information on activity, patient weight and pricing. In order to clarify the relation between dosage and patient weight, he asked the physics staff to perform a second check of the records. When the requested check was done the following error was discovered. Upon re-evaluation of the treatment procedure, the physics staff determined that the dosage of 91 mCi received from the pharmacy was not correctly calculated for the patient weight that was specified on the original order. The pharmacy was then requested to fax back the original order (Form J). The fax which they sent confirmed the correct weight of the patient (148 lbs). For this weight a correct calculation would have indicated an activity of 67.13 mCi. Instead the pharmacy had shipped the (incorrect) activity of 91 mCi. The resulting delivered dosage was 29.5 (percent) more than the prescribed dose. Thus (the staff) concluded that a medical event had occurred. The Radiation Oncologist notified the referring physician on February 16, 2016. The Radiation Oncologist also will note this communication in the patient's chart. Florida Incident Number: FL 16-029 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 48411 | 15 October 2012 07:00:00 | Agreement State | Agreement State Report - Dose Different from Prescribed | The following report was received from the Nevada Radiation Control Program via e-mail: We would just like to inform you of a medical event. Preliminary info: Yesterday (10-15-2012) we received a call from the RSO of 21st Century Oncology, regarding an incident that occurred with their HDR. Due to a faulty ruler, a parameter was entered incorrectly in the HDR control panel, resulting in a dose to the skin of the patient of around 160 centiGray. The skin area was one cubic cm. The intended dose was 160-170 cGy (to a different treatment site). The intended target was an almost spherical volume located in the right breast. The skin that was exposed is located in the right breast, at the entrance of the device (multi lumen mammosite) catheter. The closest organ is the right lung. The patient is fine and was informed of this. The sealed source remained inside the tube. (The event is) being reported under 10 CFR 35.3045 (a)(3): A dose to the skin or an organ or tissue other than the treatment site that exceeds by 0.5 Sv (50 rem) to an organ or tissue and 50 percent or more of the dose expected from the administration defined in the written directive (excluding, for permanent implants, seeds that were implanted in the correct site but migrated outside the treatment site). 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 42556 | 31 March 2006 04:00:00 | Agreement State | Agreement State Report - Medical Event | An 80 year old white female undergoing a Mammosite Brachytherapy (Nuclear Tron V2 model 31662) procedure utilizing Ir-192 source received less than 30% of the prescribed dose of 3400 centi-gray (cGy) (accumulated dose). An incorrect figure was entered into the computer causing the source to stay back 6 cm from the intended position and hence dosing an unintended area of approximately 2 cm with 3 times the prescribed dose of 10,000 cGy. The treatment was given 2 times a day for five days from March 31 to April 7, 2006. The patient saw the attending physician for follow-up on May 2, 2006. The physician discovered the patients skin abnormally red. He contacted the Medical Physicist who investigated and discovered the input error. The physician, patient and the patients family were notified. The patient is well and is being treated for erythema. Florida Incident number: FL 06-062 |