ENS Event | |
|---|---|
04:00 Jul 3, 2006 | |
| Title | Agreement State Report - Medical Misadministration Using High Dose Rate Afterloader |
| Event Description | On 7/17/06 the State of Maryland received a report from the Anne Arundel Medical Center in Annapolis, Maryland of a potential medical misadministration using a high dose rate afterloader.
Approximately two to three weeks ago a patient was administered a dose using a Varian VariSource 200 HDR brachytherapy afterloader to treat a lung tumor. During the dose administration the catheter was determined to be about ten centimeters short of the planned location for the dose. Because of the mispositioning or the catheter, an unintended dose of less than 100 centigray was given to patient's vocal chord area. The lungs received a dose of 5 gray. The licensee notified the patient of the issue. A licensee physician examined the patient today and determined that there was no erythema and that there would be no adverse medical effects in the unintended dose area. The licensee reported that a human error not a device error resulted in the misadministration. The State will be conducting follow-up investigations into this incident to include reviewing the licensee's determination of the cause, as well as, determining why the event was not reported until 2 to 3 weeks after it had occurred. Typically a 10 curie Iridium-192 source is used in this type of instrument.
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| Where | |
|---|---|
| Anne Arundel County Medical Center Annapolis, Maryland (NRC Region 1) | |
| License number: | MD-0300106 |
| Organization: | Maryland Dept Of The Environment |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+346.92 h14.455 days <br />2.065 weeks <br />0.475 months <br />) | |
| Opened: | Ray Manley 14:55 Jul 17, 2006 |
| NRC Officer: | Pete Snyder |
| Last Updated: | Jul 18, 2006 |
| 42707 - NRC Website | |
Anne Arundel County Medical Center with Agreement State | |
WEEKMONTHYEARENS 427072006-07-03T04:00:0003 July 2006 04:00:00
[Table view]Agreement State Agreement State Report - Medical Misadministration Using High Dose Rate Afterloader 2006-07-03T04:00:00 | |