ENS 46859
ENS Event | |
|---|---|
04:00 Jul 2, 2007 | |
| Title | Agreement State Report - Medical Misadministration Using Hdr Afterloader |
| Event Description | The following was received from the State of New York via fax:
New York law prohibits the release of any identifiers in cases of medical events. Therefore, the facility name etc. is not contained in this report. The licensee called on 7/2/07 to report an event involving HDR unit. Patient did not get incorrect treatment. In fact patient did not receive any therapeutic dose on this session. Here is what happened. A patient was receiving mammosite therapy with the Nucletron HDR unit. During this session, the therapist went into the treatment room, and placed the transfer tube on the patient (across from right superior to left inferior) but did not connect it to the catheter in the patient's breast. Then she went out to get the doctor. Neither of them checked to make sure that the catheter was connected to the transfer tube through the connector. Then they delivered the treatment. Since the mammosite connector (closed end) was attached to the transfer tube tune, there was no interlock. But there was no sensor or interlock to inform them that there was nothing connected to the other end of this connector. So the source proceeded as programmed and stuck out 16 cm from the end of the transfer tube in the connector tube. They saw this only when they went in to disconnect after treatment. According to their calculations, the source was at distance of 38 cm from the patient's left leg. Notice that the transfer tube is part of Nucletron equipment. The connector that connects from the transfer tube to the catheter is part of mammosite (Cytec) equipment. There was no sensor to ensure that this connection was made. It appears that the connector's closed end was sticking out in the air by the patient's leg and the programmed positions for treatment resulted in the source being in the connector in air about 16 cm from the patient's left leg. Physician/RSO admitted over the phone that the treating physician did not check the applicator and connection prior to treatment. The patient received the correct treatment later. Policy and procedure reviewed. 'The physician will log into the treatment system to initiate treatment delivery and he will be responsible to ensure that all treatment parameters and connections are satisfied'. A copy of the Cytec and Medwatch correspondence was included with the documentation. This case can now be closed. HDR Brachytherapy event (NYS DOH Internal Tracking No. 553). NY Event Report Number: NY-11-02. 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 | |
|---|---|
| None Provided New York (NRC Region 1) | |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+34017.05 h1,417.377 days <br />202.482 weeks <br />46.597 months <br />) | |
| Opened: | None Provided 13:03 May 19, 2011 |
| NRC Officer: | Joe O'Hara |
| Last Updated: | May 19, 2011 |
| 46859 - NRC Website | |
None Provided with Agreement State | |
WEEKMONTHYEARENS 468612007-10-02T04:00:0002 October 2007 04:00:00
[Table view]Agreement State Agreement State Report - Patient Received Twice the Prescribed Dose ENS 468592007-07-02T04:00:0002 July 2007 04:00:00 Agreement State Agreement State Report - Medical Misadministration Using Hdr Afterloader ENS 468602007-06-20T04:00:00020 June 2007 04:00:00 Agreement State Agreement State Report - Medical Misadministration Using Hdr Afterloader 2007-07-02T04:00:00 | |