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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 40413 | 22 December 2003 18:00:00 | Agreement State | Ohio Agreement State Report - Radiation Dose to Unintended Site During Brachytheraphy Treatment | On 12/23/2003 at 1600 hours EST the licensee notified the Ohio Department of Health, Bureau of Radiation Protection, of the following information regarding a patient undergoing intravascular brachytheraphy treatment: On December 22, 2003 during a treatment with a Novoste Beta-Cath 3.5 French IVB System, the source did not travel the entire way to the treatment site and was 3 centimeters proximal to the treatment site. The immediate cause of the event was a small kink in the delivery catheter which kept the source train from traveling to the correct site, even though the kink was not substantial enough to affect the flow of sterile water used to send/retrieve the sources. The error was discovered the next day during medical physics quality checks and reported to Ohio Department of Health, Bureau of Radiation Protection. An investigation will be performed the week of December 29, 2003. The dose to the unintended site was identified as 1840 rad (18.4 Gy) from a 0.05378 curie, Sr-90, sealed source. The attending physician has been notified. The intravascular brachytheraphy unit is a Novoste, model TDA-1040, serial number 91828. The Ohio Department of Health, Bureau of Radiation Protection reference number for this event is 2003-126. |