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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 53187 | 29 January 2018 15:30:00 | 10 CFR 35.3045(a)(1) | Received Dose Greater than Prescribed Dose | A patient received SAVI (Strut-Adjusted Volume Implant) High Dose Rate Treatments on January 26, 2018 and January 29, 2018. After the treatment, it was noted that the dwell time on one catheter appeared unusual. The treatment from January 26 was then reviewed and it was discovered that the catheters were labeled incorrectly during the initial treatment planning process. The physician was notified to review the delivered dose. Another physicist was contacted and remotely viewed the delivered treatment of the January 29 treatment as well as the treatment plan from January 26. This physicist came to the same conclusion that the catheters had been mislabeled on the January 26 CT scan. The skin received a greater dose than intended for one delivered fraction. 1cc received 848cGy, intended 256cGy and 0.1cc received 1500cGy, intended 282cGy. A decision was made by the physician to cancel all further radiation treatments using the SAVI device and the catheter was removed. The patient was notified of the event, as well as the referring physicians. 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. |