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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 53040 | 27 October 2017 19:28:00 | 10 CFR 35.3045(a)(1) | Medical Event - Dose Misadministration | A patient receiving treatment for a liver disease was prescribed 60 milliCuries of Y-90 SIR-Spheres. The delivered dose was calculated to be 11 milliCuries and stasis was not achieved. The patient was notified of the misadministration and is scheduled to receive the fully prescribed dose. 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 41881 | 21 July 2003 06:00:00 | 10 CFR 35.3045(a)(1) | Medical Event - Dose Both Greater than and Less than Prescribed | An independent review of HDR (High Dose Rate) treatment records occurred on July 28, 2005. During this review, a Medical Event was discovered which meets reporting requirements of 10 CFR 35.3045. On July 21, 2003, an 87 year old male received what was to be the first of two High Dose Rate (HDR) treatments for esophageal cancer using a remote afterloading unit. The physician Authorized User prescribed a dose of 500 cGy (centiGray) at 0.5 cm from the surface of the NG (naso-gastric) tube for an active length of 5.5 cm using a 5.551 Curie iridium-192 source. The treatment plan called for 12 indexer step positions at 5.0 mm spacing. The medical physicist entered 12 indexer step positions with 2.5 mm spacing and treatment was delivered. On August 14, 2003, the second fraction occurred without incident. A simulated plan was calculated on July 29, 2005, to reproduce the initial treatment plan and actual treatment delivered. The simulations suggest the patient may have received as much as 74% over dosage to a portion of his esophagus and as much as 92% under dosage to a portion of his esophagus. The patient returned to the facility on July 14, 2005, for treatment and is currently under our care. |