ENS Event | |
|---|---|
04:00 Jun 26, 2019 | |
| Title | Agreement State Report - Brachytherapy Underdose Due to Dislodging of Device |
| Event Description | The following was received via e-mail:
A patient was planned for a HDR [high dose rate] brachytherapy vaginal cuff treatment, fraction 1 of 2, at 5 Gy per fraction. A vaginal cylinder was placed in the vaginal canal and the positioning was verified with a cone beam CT scan. The cylinder was then connected to the afterloader containing the Ir-192 source [3.449 Ci; GammaMed 232 S/N: 24-01-7273-001-020819-12601-99] and treatment commenced. Upon completion of the treatment, it was observed that the vaginal cylinder was dislodged from the initial position. The cylinder was found between the legs, outside the vaginal canal, in contact with the perineal region. The patient indicated that she had coughed at some point during the treatment, which may have contributed to the dislodgement of the cylinder. The estimated skin dose is 5 Gy (500 rad). No erythema was observed at the time of discovery. The patient and referring physician have been notified. Ohio Item Number: OH190009 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.
The following retraction information was obtained from the state of Ohio via email: An inspection was conducted on July 15, 2019 to investigate the event. It was determined that the applicator was properly secured for the prescribed treatment, but was dislodged by the patient. Since the cause was patient intervention, this is not a medical event. Notified R3DO (Edwards) and NMSS Events Notification (email). |
| Where | |
|---|---|
| The Cleveland Clinic Foundation Sandusky, Ohio (NRC Region 3) | |
| License number: | 02230220000 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+33.53 h1.397 days <br />0.2 weeks <br />0.0459 months <br />) | |
| Opened: | Michael Rubadue 13:32 Jun 27, 2019 |
| NRC Officer: | Jeffrey Whited |
| Last Updated: | Jul 17, 2019 |
| 54136 - NRC Website | |
The Cleveland Clinic Foundation with Agreement State | |
WEEKMONTHYEARENS 541362019-06-26T04:00:00026 June 2019 04:00:00
[Table view]Agreement State Agreement State Report - Brachytherapy Underdose Due to Dislodging of Device ENS 536132018-09-19T04:00:00019 September 2018 04:00:00 Agreement State Agreement State Report - Package Arrived with Surface Contamination 2019-06-26T04:00:00 | |