ENS Event | |
|---|---|
21:30 Mar 29, 2006 | |
| Title | Different Length Bucket and Applicator Used During Brachytherapy Dose |
| Event Description | Following a vaginal/cervical/uterine brachytherapy dose it was noted during a side by side comparison that a different length bucket and applicator were used. Because the applicator was shorter than the bucket, the applicator did not reach the end of the bucket during administration of the dose. Review of the x-ray taken to confirm placement during the exam confirmed that a different dose distribution was given to the patient than originally intended. It is estimated that the dose varied by greater than 20 percent. The dose was lower than the intended dose.
The prescribing physician did not note any apparent ill effects to the patient during a follow-up physical examination. This occurred because the licensee did not do a direct physical comparison of the bucket and applicator prior the exam. The licensee sorted all applicators and buckets following the event to create matched sets. The licensee is considering modifying procedures to include physical comparison of the applicator and bucket in the future. The oncology physician was to inform the patient of the differing dose. |
| Where | |
|---|---|
| Indiana University Medical Center Indianapolis, Indiana (NRC Region 3) | |
| License number: | 13-02752-03 |
| Organization: | Indiana University Medical Center |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+14.18 h0.591 days <br />0.0844 weeks <br />0.0194 months <br />) | |
| Opened: | Mack Richard 11:41 Mar 30, 2006 |
| NRC Officer: | Pete Snyder |
| Last Updated: | Mar 30, 2006 |
| 42453 - NRC Website | |
Indiana University Medical Center with 10 CFR 35.3045(a)(1) | |
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