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The following information was received by … The following information was received by e-mail:</br>On March 25, 2010, Mayo Clinic notified the Minnesota Department of Health of an HDR (High Dose Rate After Loader) medical event. The patient was prescribed four fractions of 4 Gy for a biliary HDR treatment. The catheter had been placed and imaged. A dummy source was pushed into the catheter until it met resistance that was assumed to be the end of the catheter. In fact, the resistance was a tight bend approximately 17 centimeters (6.69 inches) short of the end.</br>The distance that was thought to be the end of the catheter was incorrectly used for the treatment distance and the patient was subsequently treated. Prior to treatment the following day, a dummy source was again inserted. That source extended beyond the programmed distance. An x-ray revealed that the end of the catheter was beyond the initial treatment location.</br>For the first two fractions, the HDR source was 17 cm from its intended treatment location. This resulted in the tumor receiving only 30 percent of the intended fractional dose and resulted in the duodenum (where the HDR source was located) receiving more than 50 rem and more than 50 percent of planned.</br>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.necessarily result in harm to the patient. +
05:00:00, 23 March 2010 +
45,788 +
15:27:00, 25 March 2010 +
05:00:00, 23 March 2010 +
The following information was received by … The following information was received by e-mail:</br>On March 25, 2010, Mayo Clinic notified the Minnesota Department of Health of an HDR (High Dose Rate After Loader) medical event. The patient was prescribed four fractions of 4 Gy for a biliary HDR treatment. The catheter had been placed and imaged. A dummy source was pushed into the catheter until it met resistance that was assumed to be the end of the catheter. In fact, the resistance was a tight bend approximately 17 centimeters (6.69 inches) short of the end.</br>The distance that was thought to be the end of the catheter was incorrectly used for the treatment distance and the patient was subsequently treated. Prior to treatment the following day, a dummy source was again inserted. That source extended beyond the programmed distance. An x-ray revealed that the end of the catheter was beyond the initial treatment location.</br>For the first two fractions, the HDR source was 17 cm from its intended treatment location. This resulted in the tumor receiving only 30 percent of the intended fractional dose and resulted in the duodenum (where the HDR source was located) receiving more than 50 rem and more than 50 percent of planned.</br>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.necessarily result in harm to the patient. +
Has query"Has query" is a predefined property that represents meta information (in form of a <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Subobject">subobject</a>) about individual queries and is provided by <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Help:Special_properties">Semantic MediaWiki</a>.
00:00:00, 25 March 2010 +
1047-205-55 +
Modification date"Modification date" is a predefined property that corresponds to the date of the last modification of a subject and is provided by <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Help:Special_properties">Semantic MediaWiki</a>.
22:30:36, 24 September 2017 +
15:27:00, 25 March 2010 +
2.435 d (58.45 hours, 0.348 weeks, 0.0801 months) +
05:00:00, 23 March 2010 +
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