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| Entered date | Event description | |
|---|---|---|
| ENS 41881 | 29 July 2005 15:55:00 | An independent review of HDR (High Dose Rate) treatment records occurred on July 28, 2005. During this review, a Medical Event was discovered which meets reporting requirements of 10 CFR 35.3045. On July 21, 2003, an 87 year old male received what was to be the first of two High Dose Rate (HDR) treatments for esophageal cancer using a remote afterloading unit. The physician Authorized User prescribed a dose of 500 cGy (centiGray) at 0.5 cm from the surface of the NG (naso-gastric) tube for an active length of 5.5 cm using a 5.551 Curie iridium-192 source. The treatment plan called for 12 indexer step positions at 5.0 mm spacing. The medical physicist entered 12 indexer step positions with 2.5 mm spacing and treatment was delivered. On August 14, 2003, the second fraction occurred without incident. A simulated plan was calculated on July 29, 2005, to reproduce the initial treatment plan and actual treatment delivered. The simulations suggest the patient may have received as much as 74% over dosage to a portion of his esophagus and as much as 92% under dosage to a portion of his esophagus. The patient returned to the facility on July 14, 2005, for treatment and is currently under our care. |
| ENS 55635 | 9 December 2021 11:19:00 | The following is a summary of information received via telephonic conversation from the Radiation Safety Officer at Saint Vincent Indianapolis Hospital: At 1000 EST on December 8, the health physicist became aware that on the previous day a patient was treated with the wrong plan parameters. The patient was given a dose on the same organ as the assigned patient on the treatment report with nearly the same prescribed dose. The total dose was 3030 cGy, which is 1 percent higher than the prescribed dose of 3000 cGy that the patient was prescribed. The treatment was completed with no unintended harm to the patient. The second patient was not affected by the error. The event is being reported under 10CFR35.3045(a)(2) for an administration of a dose or dosage to the wrong individual. 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. |