ENS 44788
ENS Event | |
|---|---|
06:00 Dec 23, 2008 | |
| Title | Agreement State - Medical Misadministration |
| Event Description | The following was provided by the state via facsimile:
Description and Analysis of event: A medical event was discovered at 11:00 AM on January 2, 2009 involving a patient who was undergoing high dose rate brachytherapy (HDR) for papillary serous adenocarcinoma of the uterus. The patient completed 4600cGy of external beam radiation therapy on 9/11/08 and was currently undergoing 3 high dose rate brachytherapy fractions, approximately 3 cm in length, at 500 cGy per fraction. During the patient's second HDR treatment, a review of the first HDR plan showed that the tandem was not fully inserted into the cylinder. The visualization on the CT scan of the placement of the tandem being partially inserted was not recognized by the planner or reviewer of the plan. The dwell positions were therefore placed in the airspace where the tandem should have been inserted versus at the retracted location. The first fraction (12/23/08) was therefore treated approximately 6 cm distal to what was represented by the isodoses on the plan printout. The x-ray (port film) at the time of treatment also showed the tandem not fully inserted into the cylinder. A plan was run with the isodoses placed 6 cm distal to the tip of the tandem channel. The isodoses show that the patient received dose (3 cm of active dwell positions as planned) to the distal vagina versus the proximal vagina as prescribed. The radiation oncologist was immediately notified of the tandem placement after discovery. The prescribing physician (radiation oncologist) notified the patient and the referring physician about the variance that had occurred in the patient's treatment as well as the possible complications. Patient Management: The radiation oncologist explained to the patient that there was no clinically significant increase in possible complications as a result of the HDR treatment to the distal vagina for 1 fraction (12/23/08). After careful review, the radiation oncologist decided he will continue as planned with the third HDR fraction at 500 cGy. He does not expect any increase in bladder or rectal toxicity and expects to see a decrease in normal tissue toxicity. Prevention of Future Occurrence: 1. When the nurse assembles the cylinder applicator, the nurse will measure the tandem length outside the cylinder to ensure the tandem has been inserted to the maximum extent. 2. The dosimetry and physics staff will receive an in-service on the difference in CT image based plans with an emphasis on how the tandem channel looks in the cylinder with the tandem fully inserted versus a partial insertion. 3. The physicists will begin looking at the pre-treatment port film along with the radiation oncologist prior to initiating treatment. Louisiana event number - LA090007 A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient. |
| Where | |
|---|---|
| Mary Bird Perkins Cancer Center Baton Rouge, Louisiana (NRC Region 4) | |
| License number: | LA-2651-L01 |
| Organization: | Louisiana Radiation Protection Div |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+680.18 h28.341 days <br />4.049 weeks <br />0.932 months <br />) | |
| Opened: | Ann Troxler 14:11 Jan 20, 2009 |
| NRC Officer: | Jason Kozal |
| Last Updated: | Jan 20, 2009 |
| 44788 - NRC Website | |
Mary Bird Perkins Cancer Center with Agreement State | |
WEEKMONTHYEARENS 580242025-07-01T06:00:0001 July 2025 06:00:00
[Table view]Agreement State Medical Event ENS 458762010-03-15T12:30:00015 March 2010 12:30:00 Agreement State Radiation Underdose at Prescribed Location ENS 447882008-12-23T06:00:00023 December 2008 06:00:00 Agreement State Agreement State - Medical Misadministration ENS 422632005-11-22T06:00:00022 November 2005 06:00:00 Agreement State Agreement State Report - Medical Event 2025-07-01T06:00:00 | |