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| Entered date | Event description | |
|---|---|---|
| ENS 43145 | 5 February 2007 13:56:00 | A FS (Tandem and ovoid) device was loaded into a patient for Cs-137 brachytherapy of the cervix on Friday Feb 2, 2007. The written directive was for 3000 cGy to Pt A in 48.5 hours. Upon removal of the device on Sunday Feb 4, 2007 at approximately 5PM it was observed that the plastic tube used to hold the Cs sources in the tandem was not of the standard length: it was short by approximately 4 cm. The consequence of this would be that the tandem sources would not have been in the position planned. The patient received an underdose to Point A of 760 cGy vs. the 3000 cGy that had been prescribed. Follow-up treatment is planned to correct for this underdose. Clinically, according to the physician, the dose the patient received to distal vaginal would not be expected to cause adverse reactions. " * * * UPDATE FROM FLANNERY (FSME) TO HUFFMAN VIA E-MAIL AT 1218 EST ON 2/06/07 * * * This event has been reviewed by the NRC medical review committee and determined to be a reportable medical event. 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. |