Semantic search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 53343 | 17 April 2018 04:00:00 | 10 CFR 35.3045(a)(1) | Written Directive for Ra-223 Administration Incorrect | A quarterly review conducted on 4/17/18, identified that the written directive for administration of Ra-223 was incorrect. The written directive stated that the Ra-223 should be administered orally, but should have stated that it was to be administered intravenously (IV). The review determined that there was no impact to any patients as a result of the error in the written directive. The review identified one case where the written directive was used. However, the technician administered the Ra-223 to the patient via IV and not orally. The corrective actions taken by the licensee were to correct the written directive, and review the directive with the technician to understand why the technician did not consult with the physician when there was an error in the directive. The licensee notified the NRC R3 Office (Warren). 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 46224 | 30 August 2010 18:00:00 | 10 CFR 35.3045(a)(1) | Misplaced Palliative Source Implants | On August 30, 2010, a patient was implanted with I-125 seeds in the anus for a palliative procedure. Two days later, September 1, 2010, a follow-up CT scan on the patient showed that the implants had been inserted 4 cm superior to the intended location which would lead to less dose at the target location. The intended dose was 90 Gy to the anus. More imaging studies are planned to estimate the actual dose to the intended target area. The patient will be implanted again after the imaging study is complete. A decision will be made at that time whether to correct the original implants. The reason for the error is believed to be twofold: The tumor had progressed markedly since the original planning and the decision was made to correct the plan for the additional growth based on palpation indications. Also, the 10 cm mark on the needle may have been mistaken for the 5 cm mark. No long term complications are anticipated. Both patient and physician have been informed.
The licensee is updating this report to provide the results of the normal tissue doses from the permanent implants at the end of the treatment plan to the following organs: Bladder: Prescribed .07 Gy - Delivered 3.75 Gy Seminal Vesicles: Prescribed 5.38 Gy - Delivered 25.17 Gy Prostate: Prescribed 6.24 Gy - Delivered 4.2 Gy Rectum: Prescribed 45.18 Gy - Delivered 3.16 Gy The above information will be provided in the 15-day written report. Notified R3DO (Hills) and FSME (Burgess). 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. |