ENS 44137: Difference between revisions
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| event date = 12/11/2007 CDT | | event date = 12/11/2007 CDT | ||
| last update date = 04/14/2008 | | last update date = 04/14/2008 | ||
| title = Agreement State Report - Mississippi - Misadministration Involving | | title = Agreement State Report - Mississippi - Misadministration Involving an Hdr Treatment | ||
| event text = The State provided the following information via email: | | event text = The State provided the following information via email: | ||
On 3-26-08, licensee's RSO notified DRH [Mississippi Division of Radiation Health] of a Iridium-192 HDR treatment misadministration. The reportable event involves the administration of 3 separate fractions for one (1) patient over a six (6) day period. The misadministration was caused by not measuring the catheters. Measurements taken on 3-25-08 of the tandem and ovoid applicators connected to the Varion Varisource HDR indicated that the length of the source wire entered in the treatment planning system should be 128 cm instead of 120 cm. Further inspection of the catheters revealed that the ovoid catheters were correct but the tandem catheter should have been used with a different applicator. The error resulted in the dose being delivered approximately 86 mm inferior to the desired location. The prescribed treatment was for 5 fractional treatments for 600 cGy each (3000 cGy total); however, due to the error only 470 cGy was administered in 3 treatments (26% of the prescribed dose). It was noted during the investigation by DRH that for other problems not associated with the HDR treatments, the patient did not return for the final 2 fractional doses. The dose to the vaginal region inferior to the treatment area received a 1300 cGy overexposure as a result of the error. The Radiation Oncologist does not foresee this patient experiencing adverse health effects as a result of this misadministration. The referring physician and the patient have been notified. | On 3-26-08, licensee's RSO notified DRH [Mississippi Division of Radiation Health] of a Iridium-192 HDR treatment misadministration. The reportable event involves the administration of 3 separate fractions for one (1) patient over a six (6) day period. The misadministration was caused by not measuring the catheters. Measurements taken on 3-25-08 of the tandem and ovoid applicators connected to the Varion Varisource HDR indicated that the length of the source wire entered in the treatment planning system should be 128 cm instead of 120 cm. Further inspection of the catheters revealed that the ovoid catheters were correct but the tandem catheter should have been used with a different applicator. The error resulted in the dose being delivered approximately 86 mm inferior to the desired location. The prescribed treatment was for 5 fractional treatments for 600 cGy each (3000 cGy total); however, due to the error only 470 cGy was administered in 3 treatments (26% of the prescribed dose). It was noted during the investigation by DRH that for other problems not associated with the HDR treatments, the patient did not return for the final 2 fractional doses. The dose to the vaginal region inferior to the treatment area received a 1300 cGy overexposure as a result of the error. The Radiation Oncologist does not foresee this patient experiencing adverse health effects as a result of this misadministration. The referring physician and the patient have been notified. | ||
Revision as of 22:14, 1 March 2018
| Where | |
|---|---|
| University Of Mississippi Medical Center Jackson, Mississippi (NRC Region 4) | |
| License number: | Ms-Mbl-01 |
| Organization: | Mississippi Div Of Rad Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+3007.37 h125.307 days <br />17.901 weeks <br />4.119 months <br />) | |
| Opened: | Bobby Smith 11:22 Apr 14, 2008 |
| NRC Officer: | Bill Huffman |
| Last Updated: | Apr 14, 2008 |
| 44137 - NRC Website | |