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| Entered date | Event description | |
|---|---|---|
| ENS 41361 | 27 January 2005 13:00:00 | A patient undergoing a 31 hour treatment plan for cervical cancer received less than the prescribed dose delivered to the treatment site and a higher than intended dose to other tissue(s)/organ(s), specifically: Treatment site A: planned 1643 centiGray, delivered 821 centiGray Treatment site B: planned 465 centiGray, delivered 372 centiGray Bladder: planned 1147 centiGray, delivered 1448 centiGray Rectum: planned 1147 centiGray, delivered 2012 centiGray Treatment was delivered from 1430 hours on 1/24 and 2130 hours on 1/25 using a low dose rate tandem brachytherapy device containing three Cs-137 sources; 14 milligram Ra-equiv, 9.8 milligram Ra-equiv and 9.8 milligram-equiv. There were two additional Cs-137 ovoid sources, each 14.1 milligram Ra-equiv. The tandem device has a rod that was cut 6 cm. short such that when the tandem was positioned in the patient, the three tandem sources were not extended the proper distance inside the tandem device. The ovoid sources were properly positioned. The referring physician and patient have been informed. The radiation staff oncologist does not believe that this medical event will have any adverse effect on the patient and a new treatment plan is being prepared for the patient. |