ENS Event | |
|---|---|
01:00 Dec 7, 2011 | |
| Title | Agreement State Report - Possible Medical Event |
| Event Description | The following was received from the State of Minnesota via email:
Minnesota Department of Health (MDH) was initially notified on December 14, 2011, by a representative from the University of Minnesota about a possible HDR [High Dose Rate] medical event. As of December 15, 2011 MDH was notified of the determination of a medical event that resulted in a 50% overexposure to an unintended area.
This notification is to provide follow-up information to the medical event initially reported on 12/15/2011 by Lynn Dunbar of the Minnesota Department of Health. The patient was being treated for uterine cancer using iridium 192 high dose-rate (HDR) brachytherapy. The written directive called for treating the target area to approximately 600 cGy per fraction for five fractions. Instrumentation consisted of four plastic Heyman capsules, a tandem, and a pair of ovoids. Of the seven pathway options, five were identified to be used in the treatment plan for delivering the dose, and catheters were inserted into these instruments. The first fraction of five was delivered with the tandem catheter not fully inserted into the tandem. The second of five fractions was delivered according to the original written directive. The 3rd, 4th, 5th fractions were modified to give the treatment volume the originally intended total dose. The dose to the rectum would have been 157.5 cGy if all five fractions were completed according to the original written directive. The dose to the rectum as treated was 256.2 cGy, about 63% more than intended. The Event Date provided in the initial report was changed (from 12/15/2011 to 12/6/2011) and the number given as the 'MDH #' (MDH #: 1049-206-27) was re-assigned as the licensee's license number based on information provided in the update. 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 | |
|---|---|
| University Of Minnesota Minneapolis, Minnesota (NRC Region 3) | |
| License number: | 1049-206-27 |
| Organization: | Minnesota Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+208.72 h8.697 days <br />1.242 weeks <br />0.286 months <br />) | |
| Opened: | Lynn Dunbar 17:43 Dec 15, 2011 |
| NRC Officer: | Charles Teal |
| Last Updated: | Dec 23, 2011 |
| 47528 - NRC Website | |
University Of Minnesota with Agreement State | |
WEEKMONTHYEARENS 559472022-06-14T05:00:00014 June 2022 05:00:00
[Table view]Agreement State Dose Misadministration ENS 491022012-08-22T05:00:00022 August 2012 05:00:00 Agreement State Agreement State Report - Potential Medical Overdose ENS 475282011-12-07T01:00:0007 December 2011 01:00:00 Agreement State Agreement State Report - Possible Medical Event ENS 460152010-06-15T17:15:00015 June 2010 17:15:00 Agreement State Agreement State Report - Gamma Knife Treatment Administered to Wrong Location 2022-06-14T05:00:00 | |