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| Entered date | Event description | |
|---|---|---|
| ENS 47646 | 8 February 2012 12:18:00 | The following was received from the state of New Jersey via email: A patient was treated with a Varian VariSourceTM HDR unit on February 7, 2012. The prescription dose was 200 cGy per fraction for 8 fractions. The first two fractions were delivered to the patient with a fractional dose of 25 cGy instead of the prescribed fractional dose of 200 cGy before the discovery of the event around 7 p.m. on February 7, 2012. The initial treatment plan was designed for a single fractional dose of 200 cGy and was approved on screen by the physician. The plan was later modified to 8 fractions with a fractional dose of 200 cGy before the delivery of the first fraction. This modification was however done incorrectly and the isodose line of 200 cGy, instead of 1600 cGy, was planned to cover the target volume. (Isodose means a radiation dose of equal intensity to more than one body area.) Two fractions of treatment (out of a planned 8) were delivered on 2/7/2012 before discovery of the event, resulting in a dose of 25 cGy per fraction (instead of 200 cGy) prescribed to the target volume. 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 46968 | 17 June 2011 12:40:00 | At approximately 10:00 AM EDT on Friday, June 17, 2011, a resident telephoned the above licensee and reported finding an 8 Curie Pu-238 nuclear cardiac pacemaker (ARCO NU-5 s/n 001). The licensee's medical physicist who interviewed the caller, immediately contacted NJDEP RMP (New Jersey Department of Environmental Protection Radioactive Material Programs). After interviewing the medical physicist, it was learned that the resident, while cleaning and gathering personal belongings of her deceased parent, came across an envelope that contained the pacemaker. The pacemaker was initially implanted in 1973 at the licensee's location (Newark Beth Israel) and removed in 1975 at an unknown location. After the pacemaker was removed, for reasons not yet known, it came back to the residence other patient where it remained until it's discovery on 6/17/11. The medical physicist has arranged to go to the resident's apartment later in the day where he will package the pacemaker for it's return and storage at the licensee's facility. At 12:15 PM the same day, the medical physicist reported that the pacemaker was safely returned to the licensee's facility. The pacemaker was intact with no signs of damage. The licensee will attempt to locate any files/information pertaining to the patient that may still be stored from the 1970's. A full report is expected from the licensee. NJ Event ID No. NJ-11-17-06 |