ENS Event | |
|---|---|
06:00 Nov 22, 2005 | |
| Title | Agreement State Report - Medical Event |
| Event Description | The State provided the following information via facsimile:
The patient was planned to receive an HDR brachytherapy dose of 750 cGy in a single fraction to a distance of 1.0 cm beyond the active dwell positions in the right lung. A catheter was inserted in the right bronchus on November 22, 2005 for the treatment. The catheter was marked at the entrance of the nostril and taped to the nose and face. The patient was then taken to CT for the treatment planning. The treatment plan was developed and approved. The patient was treated in a linear accelerator vault. Prior to treatment, a dummy wire was placed into the catheter and a megavoltage portal image was taken to confirm placement of the catheter. The radiation oncologist believed that he had verified the catheter placement from the portal image. The catheter was connected to the HDR unit and the treatment was performed. At the conclusion of the treatment, the prescribing physician and nurse entered the treatment room to remove the catheter from the patient. At that time it was discovered that the catheter was not fully inserted into the patient's lung. The mark that was put on the catheter during the planning was 15 cm outside of the nose. Apparently the catheter had become loose from the tape. According to the prescribing physician the dose used for this treatment was not enough to produce any significant sequalae in the upper thorax and neck region. The patient was informed on 11/22/05. External beam therapy will be used for the missing dose to the lung. Some procedures have been modified to prevent this from reoccurring. LA Event Report ID No: LA050009 |
| Where | |
|---|---|
| Mary Bird Perkins Cancer Center Baton Rouge, Louisiana (NRC Region 4) | |
| License number: | La-2651-L01 |
| Organization: | Louisiana Radiation Protection Div |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1353.5 h56.396 days <br />8.057 weeks <br />1.854 months <br />) | |
| Opened: | Mike Henry 15:30 Jan 17, 2006 |
| NRC Officer: | Jeff Rotton |
| Last Updated: | Jan 17, 2006 |
| 42263 - NRC Website | |
Mary Bird Perkins Cancer Center with Agreement State | |
WEEKMONTHYEARENS 458762010-03-15T12:30:00015 March 2010 12:30:00
[Table view]Agreement State Radiation Underdose at Prescribed Location ENS 447882008-12-23T06:00:00023 December 2008 06:00:00 Agreement State Agreement State - Medical Misadministration ENS 422632005-11-22T06:00:00022 November 2005 06:00:00 Agreement State Agreement State Report - Medical Event 2010-03-15T12:30:00 | |