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The following information was obtained fro … The following information was obtained from the State of Illinois via email:</br>Licensee reported that while following up with a patient who had undergone radiation treatments following surgical removal of a breast tumor, redness, pain and swelling were occurring near the catheter insertion site. It was determined that the intended dose had been delivered with the connector end of the applicator interface identified as the reference location instead of the tip of the applicator as planned in the treatment. As a result, the 10 fractions of 340 cGy each were offset by over 4 cm for all the dwell positions within the applicator. The treatments were conducted with a strut adjusted volume implant (SAVI) applicator following an accelerated partial breast irradiation treatment regime. The catheter insertion site is estimated as having received a dose of over 13,000 R. The patient received medical treatment for the damaged tissue which would not heal. The Agency (Illinois Emergency Management Agency) is conducting an investigation into the matter to determine if the event is isolated or if other similar treatments may have had associated errors. Additional precautions have been taken by the licensee to prevent future occurrences including changing treatment planning systems, implementing additional quality assurance procedures and involving additional personnel to verify plans before treatment commences. </br>This event was reported to the US NRC Operations Center on February 13, 2015 and assigned event number 50818.</br>This item remains open pending additional investigation results.</br>The HDR source was 6.95 Ci of Ir-192. As a result of the damage to the tissue, a mastectomy was performed.</br>IL Report Number: IL15001</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. +
06:00:00, 21 November 2014 +
50,818 +
10:43:00, 13 February 2015 +
06:00:00, 21 November 2014 +
The following information was obtained fro … The following information was obtained from the State of Illinois via email:</br>Licensee reported that while following up with a patient who had undergone radiation treatments following surgical removal of a breast tumor, redness, pain and swelling were occurring near the catheter insertion site. It was determined that the intended dose had been delivered with the connector end of the applicator interface identified as the reference location instead of the tip of the applicator as planned in the treatment. As a result, the 10 fractions of 340 cGy each were offset by over 4 cm for all the dwell positions within the applicator. The treatments were conducted with a strut adjusted volume implant (SAVI) applicator following an accelerated partial breast irradiation treatment regime. The catheter insertion site is estimated as having received a dose of over 13,000 R. The patient received medical treatment for the damaged tissue which would not heal. The Agency (Illinois Emergency Management Agency) is conducting an investigation into the matter to determine if the event is isolated or if other similar treatments may have had associated errors. Additional precautions have been taken by the licensee to prevent future occurrences including changing treatment planning systems, implementing additional quality assurance procedures and involving additional personnel to verify plans before treatment commences. </br>This event was reported to the US NRC Operations Center on February 13, 2015 and assigned event number 50818.</br>This item remains open pending additional investigation results.</br>The HDR source was 6.95 Ci of Ir-192. As a result of the damage to the tissue, a mastectomy was performed.</br>IL Report Number: IL15001</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, 13 February 2015 +
IL-01034-02 +
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>.
23:06:28, 24 November 2018 +
10:43:00, 13 February 2015 +
84.197 d (2,020.72 hours, 12.028 weeks, 2.768 months) +
06:00:00, 21 November 2014 +
URL"URL" is a <a href="/Special:Types/URL" title="Special:Types/URL">type</a> and predefined property provided by <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Help:Special_properties">Semantic MediaWiki</a> to represent URI/URL values.