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On 7/17/06 the State of Maryland received … On 7/17/06 the State of Maryland received a report from the Anne Arundel Medical Center in Annapolis, Maryland of a potential medical misadministration using a high dose rate afterloader. </br>Approximately two to three weeks ago a patient was administered a dose using a Varian VariSource 200 HDR brachytherapy afterloader to treat a lung tumor. During the dose administration the catheter was determined to be about ten centimeters short of the planned location for the dose. Because of the mispositioning or the catheter, an unintended dose of less than 100 centigray was given to patient's vocal chord area. The lungs received a dose of 5 gray. The licensee notified the patient of the issue. A licensee physician examined the patient today and determined that there was no erythema and that there would be no adverse medical effects in the unintended dose area. The licensee reported that a human error not a device error resulted in the misadministration.</br>The State will be conducting follow-up investigations into this incident to include reviewing the licensee's determination of the cause, as well as, determining why the event was not reported until 2 to 3 weeks after it had occurred. </br>Typically a 10 curie Iridium-192 source is used in this type of instrument.</br>* * * UPDATE AT 1100 EDT ON 07/18/06 FROM RAY MANLEY TO S. SANDIN * * *</br>The patient did not receive a dose of 5 gray to the lungs as described above. This was the prescribed dose. Also, the information is preliminary pending completion of the follow-up investigation. Notified R1DO (Kinneman) and NMSS (Morell).otified R1DO (Kinneman) and NMSS (Morell). +
04:00:00, 3 July 2006 +
42,707 +
14:55:00, 17 July 2006 +
04:00:00, 3 July 2006 +
On 7/17/06 the State of Maryland received … On 7/17/06 the State of Maryland received a report from the Anne Arundel Medical Center in Annapolis, Maryland of a potential medical misadministration using a high dose rate afterloader. </br>Approximately two to three weeks ago a patient was administered a dose using a Varian VariSource 200 HDR brachytherapy afterloader to treat a lung tumor. During the dose administration the catheter was determined to be about ten centimeters short of the planned location for the dose. Because of the mispositioning or the catheter, an unintended dose of less than 100 centigray was given to patient's vocal chord area. The lungs received a dose of 5 gray. The licensee notified the patient of the issue. A licensee physician examined the patient today and determined that there was no erythema and that there would be no adverse medical effects in the unintended dose area. The licensee reported that a human error not a device error resulted in the misadministration.</br>The State will be conducting follow-up investigations into this incident to include reviewing the licensee's determination of the cause, as well as, determining why the event was not reported until 2 to 3 weeks after it had occurred. </br>Typically a 10 curie Iridium-192 source is used in this type of instrument.</br>* * * UPDATE AT 1100 EDT ON 07/18/06 FROM RAY MANLEY TO S. SANDIN * * *</br>The patient did not receive a dose of 5 gray to the lungs as described above. This was the prescribed dose. Also, the information is preliminary pending completion of the follow-up investigation. Notified R1DO (Kinneman) and NMSS (Morell).otified R1DO (Kinneman) and NMSS (Morell). +
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, 18 July 2006 +
MD-0300106 +
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>.
23:34:44, 24 November 2018 +
14:55:00, 17 July 2006 +
14.455 d (346.92 hours, 2.065 weeks, 0.475 months) +
04:00:00, 3 July 2006 +
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.