ENS Event | |
|---|---|
05:00 May 7, 2004 | |
| Title | Agreement State Report - Medical Event |
| Event Description | The following information was obtained from the Louisiana Department of Environmental Quality via facsimile:
There was a Medical Event reported on April 7, 2004 concerning an incident that occurred on March 31-April 1, 2004. In the process of constructing a computer generated treatment plan for prostate Brachytherapy, a default switch that changes the source position calculation orientation from 'Connector End' to 'Catheter tip' was not adjusted to the correct orientation (Catheter/Needle tip). This led to the sources stopping short of the target and the total prescribed dose was not delivered. The facility was using a Nucletron Micro Selectron with a 7.315 [Curie] source of Ir-192. There was a total of three fractions for the treatment. One on March 31, 2004 and two on April 1, 2004. The total dose that was delivered was 1800 centigray to the wrong location. The misadministration is being compensated by external beam therapy. [There] are two causes for this event. The design of the default switch automatically selects an orientation that is not used at this facility and cannot be adjusted to default to the correct position. The other cause is operator error in not assuring that the orientation had been changed to read correctly. The patient is self-[referred] from Guatemala. The patient was informed immediately of the misadministration and received further external beam treatment. According to the Radiation Oncologist, no detrimental effects are expected. Actions taken to prevent further recurrence will be the addition of a visible check and documentation that the treatment plan was done with the source positions calculated from the tip end of the catheter or needle. This will be added to the pretreatment checklist which is performed and signed by the Radiation Oncologist, the Physicist, and the Dosimetrist. This checklist will be performed prior to initial treatment and at plan changes and is part of the patient's permanent record. There will also be a written notification to Nucletron regarding the potential danger of misadministration due to inability to change the default on the orientation 'switch'. The design should be that if the connector end is selected, the [planner] should be warned that this will change the source placement. |
| Where | |
|---|---|
| New Orleans Cancer Institute Memorial Medical Center New Orleans, Louisiana (NRC Region 4) | |
| License number: | LA-10853-LO1 |
| Organization: | Louisiana Radiation Protection Div |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+10.35 h0.431 days <br />0.0616 weeks <br />0.0142 months <br />) | |
| Opened: | Scott Blackwell 15:21 May 7, 2004 |
| NRC Officer: | Howie Crouch |
| Last Updated: | May 7, 2004 |
| 40732 - NRC Website | |
New Orleans Cancer Institute Memorial Medical Center with Agreement State | |
WEEKMONTHYEARENS 407322004-05-07T05:00:0007 May 2004 05:00:00
[Table view]Agreement State Agreement State Report - Medical Event 2004-05-07T05:00:00 | |