ENS 50321
ENS Event | |
|---|---|
05:00 Jul 28, 2014 | |
| Title | Agreement State Report - Medical Misadministration Due to Treatment Given to Wrong Patient |
| Event Description | The following information was obtained from the state of Texas via email:
On July 30, 2014, the Agency was notified by the licensee that a patient had received a portion of a treatment intended for a different patient. The licensee's Risk Compliance Officer (RCO) stated two patients had arrived for treatment. Both patients were female of similar size. Both were to receive treatment to the brain, one patient to the right side and the other to the left side. The treatment head frame had been placed on both patients. It was decided that patient two would be treated first. This information was not provided to the individual entering the program into the treatment system so the program for patient one was entered into the treatment system. Patient two was placed on the treatment table and the treatment started. About two minutes into the treatment, a physician reviewing the treatment realized the wrong plan for the patient was being used and halted the treatment. The licensee determined the patient received 3.7 gray to 0.5 cc of brain tissue during the treatment. The patient and the patient's physician were notified of the error. The RCO stated the patient's doctor evaluated the event and stated the patient should not experience any adverse effects from the exposure. The patient was later treated using the correct treatment plan. The licensee has implemented several corrective actions as a result of the event. They include adding a second time out prior to treatment and requiring multiple staff to identify. The device was a Leksell Gamma System Model 24001 containing about 1800 curies of cobalt-60. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9217 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 information was received via E-mail: On July 30, 2014, the Agency [Texas Department of Health Services] was notified by the licensee that a patient had received a portion of a gamma knife treatment intended for a different patient. The incident was investigated at the facility and confirmed that a patient received a portion of a fractional treatment dose intended for another patient. The treatment time was for 2.68 minutes with a calculated total dose of 3.5 gray to the centerpoint maximum with 50% to the isodose lines at 1.75 gray to the wrong patient. The error occurred due to rescheduling patient one who had a much longer treatment time than patient two. The health physicist and radiation oncologist lacked communication with nursing staff regarding the switch to treat patient two before patient one. This communication error along with a lack of patient identification played a major role in the unintended treatment process. The facility completed a root cause analysis of the problem and self-reported the incident. Corrective actions have been implemented to include new policies and procedures incorporating better scheduling, patient identification practices to include 'time outs' during the treatment process and limiting distractions during the treatment procedure. No violations were cited. Per the Texas Department of State Health Services, this event was not an Abnormal Occurrence as initially reported on 7/30/2014. Notified R4DO (Pick) and FSME Events Resource. |
| Where | |
|---|---|
| Covenant Health System Lubbock, Texas (NRC Region 4) | |
| License number: | 06028 |
| Organization: | Texas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+53.8 h2.242 days <br />0.32 weeks <br />0.0737 months <br />) | |
| Opened: | Art Tucker 10:48 Jul 30, 2014 |
| NRC Officer: | Dong Park |
| Last Updated: | Aug 29, 2014 |
| 50321 - NRC Website | |
Covenant Health System with Agreement State | |
WEEKMONTHYEARENS 503212014-07-28T05:00:00028 July 2014 05:00:00
[Table view]Agreement State Agreement State Report - Medical Misadministration Due to Treatment Given to Wrong Patient 2014-07-28T05:00:00 | |