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The following report was received from the … The following report was received from the Ohio Department of Health via email:</br>On Friday, November 10, 2017, ODH (Ohio Department of Health) received notification that a cancer patient may have received a dose greater than 50 rem at a site not intended for treatment. A follow-up call was made on Monday November 13, 2017. The licensee stated they believe the Elekta Flexitron (model 136149A02) remote afterloader software package used an incorrect catheter model during the first treatment fraction. The error was discovered while preparing the second fraction.</br>ODH will be sending an inspector to investigate the event this week.</br>See licensee initial description below:</br>A patient was planned to be treated with HDR (High Dose Rate) brachytherapy for GYN (Gynocology) cancer with three fractions. The HDR treatment was planned with a single curved catheters through a Tandem and Cylinder. A dosimetrist preformed a CT based treatment plan for the first fraction. During planning, the dosimetrist did not digitize the catheter correctly. A physicist checked the HDR plan in a hurry and failed to detect the incorrect reconstructed catheter shape in the planning software. During the treatment delivery, the delivery system translated the incorrectly reconstructed catheter as a linear catheter, resulting in the treatment length from the intended 9.0 cm to 15.7 cm. On the second fraction, a new plan was created based on the CT of the day. The dosimetrist did the digitization correctly this time. During the planning check (a routine process), the physicist noticed the differences between the two plans and discovered the error on the first fraction treatment.</br>Remote afterloader HDR</br>Device: ELEKTA </br>Model Number: 136149A02</br>Sealed Source Brachytherapy</br>Source: IR-192</br>Model Number: 136147</br>Ohio Event Number: OH170008</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, 6 November 2017 +
53,071 +
16:17:00, 14 November 2017 +
05:00:00, 6 November 2017 +
The following report was received from the … The following report was received from the Ohio Department of Health via email:</br>On Friday, November 10, 2017, ODH (Ohio Department of Health) received notification that a cancer patient may have received a dose greater than 50 rem at a site not intended for treatment. A follow-up call was made on Monday November 13, 2017. The licensee stated they believe the Elekta Flexitron (model 136149A02) remote afterloader software package used an incorrect catheter model during the first treatment fraction. The error was discovered while preparing the second fraction.</br>ODH will be sending an inspector to investigate the event this week.</br>See licensee initial description below:</br>A patient was planned to be treated with HDR (High Dose Rate) brachytherapy for GYN (Gynocology) cancer with three fractions. The HDR treatment was planned with a single curved catheters through a Tandem and Cylinder. A dosimetrist preformed a CT based treatment plan for the first fraction. During planning, the dosimetrist did not digitize the catheter correctly. A physicist checked the HDR plan in a hurry and failed to detect the incorrect reconstructed catheter shape in the planning software. During the treatment delivery, the delivery system translated the incorrectly reconstructed catheter as a linear catheter, resulting in the treatment length from the intended 9.0 cm to 15.7 cm. On the second fraction, a new plan was created based on the CT of the day. The dosimetrist did the digitization correctly this time. During the planning check (a routine process), the physicist noticed the differences between the two plans and discovered the error on the first fraction treatment.</br>Remote afterloader HDR</br>Device: ELEKTA </br>Model Number: 136149A02</br>Sealed Source Brachytherapy</br>Source: IR-192</br>Model Number: 136147</br>Ohio Event Number: OH170008</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. +
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00:00:00, 14 November 2017 +
02120780000 +
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01:41:26, 2 March 2018 +
16:17:00, 14 November 2017 +
8.47 d (203.28 hours, 1.21 weeks, 0.278 months) +
05:00:00, 6 November 2017 +
Agreement State Report - Dose Greater than 50 Rem Delivered at a Site Not Intended for Treatment +
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