ENS Event | |
|---|---|
05:00 Oct 28, 2021 | |
| Title | Dose to Unintended Organ |
| Event Description | The following was received from the Commonwealth of Pennsylvania by email:
On December 10, 2021, the Radiation Safety Officer for the licensee verbally reported a patient being treated for vaginal cancer was prescribed a 21 Gy total dose, to be delivered in 3 fractions of 7 Gy each via HDR [(high dose rate)]. The first fraction was delivered on October 28, 2021. At some point after that treatment, the patient began experiencing complications from the hysterectomy and ended up going to a different hospital for that issue. The patient did not return to the licensee's facility to complete her treatment. At the other hospital, a different Radiation Oncologist was consulted and was reviewing the patient's treatment and discovered that the treatment in October at the licensee was 3 cm off and the intestine received some fraction of the first treatment dose. It was discovered that the patient required re-suturing of the cervix and that the brachytherapy apparatus (used in the HDR treatment) passed beyond the apex of the vagina. This discovery was made yesterday, December 9, 2021. The licensee's medical physicist is currently calculating dose estimates. The referring physician is also being informed. No further information is available at this time. The Department of Environmental Protection will update this event as soon as more information is provided. PA Event Report ID No: PA210021 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 |
| Where | |
|---|---|
| Upmc Passavant Pittsburgh, Pennsylvania (NRC Region 1) | |
| License number: | PA-0310 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1039.45 h43.31 days <br />6.187 weeks <br />1.424 months <br />) | |
| Opened: | John S. Chippo 13:27 Dec 10, 2021 |
| NRC Officer: | Lloyd Desotell |
| Last Updated: | Dec 10, 2021 |
| 55640 - NRC Website | |
Upmc Passavant with Agreement State | |
WEEKMONTHYEARENS 556402021-10-28T05:00:00028 October 2021 05:00:00
[Table view]Agreement State Dose to Unintended Organ 2021-10-28T05:00:00 | |