ENS 51651
ENS Event | |
|---|---|
05:00 Dec 15, 2015 | |
| Title | Medical Event - Brachytherapy Source Not Placed In Intended Treatment Location |
| Event Description | This is a preliminary notification by the State of Maryland, Radiological Health Program of a medical event. During both the first and second of four High Dose Rate brachytherapy treatments to one of the patient's lungs occurring on December 15, 2015 and December 21, 2015, the radioactive source was incorrectly placed between 2 and 3 centimeters away from the intended placement location. The radioactive source being used was Iridium 192. The activity level of the radioactive source is unknown at this time.
The placement error was discovered during the third treatment on January 13, 2016. The reason for the placement error involved the use of an incorrect connection between the marker and the catheter. The State of Maryland, Radiological Health Program will conduct an investigation on January 18, 2016.
This updated licensee report was received from the State of Maryland via email: On January 12, 2016, while treating the third treatment fraction for an HDR patient with exuberant granulation tissue of the right lung lower lobe bronchus, we [the licensee] found out a discrepancy in our simulation imaging procedure which contributed to a geographic miss of approximately 4 cm. The geographic miss occurred for the patient's 1st and 2nd fractions on 12/15/2015 and 12/21/2015, respectively. The activity of the source was 6.9 Curies on 12/15/2015. In this procedure a dummy marker is normally sent into the catheter and radiographed to mark the dwell source position for treatment. It was found that in previous two treatments the dummy marker was not sent all the way through the catheter because it was used with an adapter piece on. The adapter piece was used with dummy markers in the previous microSelectron afterloader but it is not supposed to be used with the Flexitron afterloader system that we have been upgraded to since August 2014. The patient was treated correctly on 1/12/2016, however, the Radiation Oncologist is stating that no harm was done to the patient from the geographical miss in last two treatments. Since we reported this case to the State [Maryland Department of the Environment] on Wednesday 1/13/2016, we have found two more patients treated with intrabronchial HDR since the upgrade to Flexitron at this center that may have had a geographic miss. Investigation is still under way for these cases. Notified the R1DO (Gray) and NMSS Events Notification via email. 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 | |
|---|---|
| Radamerica Baltimore, Maryland (NRC Region 1) | |
| License number: | Md0505103 |
| Organization: | Maryland Dept Of The Environment |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+707.4 h29.475 days <br />4.211 weeks <br />0.969 months <br />) | |
| Opened: | Alan Jacobson 16:24 Jan 13, 2016 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Jan 15, 2016 |
| 51651 - NRC Website | |
Radamerica with Agreement State | |
WEEKMONTHYEARENS 516512015-12-15T05:00:00015 December 2015 05:00:00
[Table view]Agreement State Medical Event - Brachytherapy Source Not Placed in Intended Treatment Location 2015-12-15T05:00:00 | |