ENS Event | |
|---|---|
05:00 Sep 21, 2009 | |
| Title | Agreement State Report- Patient Received Improper Dosage |
| Event Description | On September 21, 2009, a patient undergoing mammosite brachytherapy did not receive the proper dose administration due to the Ir-192 (9.6 Ci) source failing to retract. The administering physician retrieved the source from the patient and placed it back in the device. A dose estimate is in progress, however, the licensee does not expect the dosage to exceed 50 percent of the prescribed dose. The afterloader was cleaned recently and the licensee does not expect any debris from the device. The State will report any results of the dose assessment.
Texas Incident Number: #8673 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 report was received via e-mail: On September 22, 2009, the Agency [Texas Department of Health] was notified of an incident that occurred on September 21, 2009 involving a patient undergoing mammosite brachytherapy. The patient did not receive the proper dose due to the Iridium (Ir)-192 (9.6 Curies) source failing to retract back into the High Dose Rate after-loader unit. The administering physician retrieved the source from the patient and placed it in a shielded container. An investigation by the Agency was performed on September 29, 2009 and it determined that this was not a reportable event because the fractionated dose delivered differed from the prescribed dose, for a single fraction, by less than 50 percent or the total dose for the prescribed treatment differed from that prescribed by less than 20 percent. Because this does not meet the criteria for a reportable medical event, the State of Texas would like to retract this report. Notified the R4DO (Pick), and FSME (Thaggard). |
| Where | |
|---|---|
| University Of Texas Southwestern Medical Center Dallas, Texas (NRC Region 4) | |
| License number: | L00384 |
| Organization: | Texas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+37.53 h1.564 days <br />0.223 weeks <br />0.0514 months <br />) | |
| Opened: | Annie Backhaus 18:32 Sep 22, 2009 |
| NRC Officer: | Dong Park |
| Last Updated: | Jan 27, 2010 |
| 45378 - NRC Website | |
University Of Texas Southwestern Medical Center with Agreement State | |
WEEKMONTHYEARENS 476982012-02-16T06:00:00016 February 2012 06:00:00
[Table view]Agreement State Agreement State Report - Misadministration of a Radiopharmaceutical ENS 453782009-09-21T05:00:00021 September 2009 05:00:00 Agreement State Agreement State Report- Patient Received Improper Dosage 2012-02-16T06:00:00 | |