ENS Event | |
|---|---|
06:00 Jul 21, 2003 | |
| Title | Medical Event - Dose Both Greater Than And Less Than Prescribed |
| Event Description | An independent review of HDR (High Dose Rate) treatment records occurred on July 28, 2005. During this review, a Medical Event was discovered which meets reporting requirements of 10 CFR 35.3045.
On July 21, 2003, an 87 year old male received what was to be the first of two High Dose Rate (HDR) treatments for esophageal cancer using a remote afterloading unit. The physician Authorized User prescribed a dose of 500 cGy (centiGray) at 0.5 cm from the surface of the NG (naso-gastric) tube for an active length of 5.5 cm using a 5.551 Curie iridium-192 source. The treatment plan called for 12 indexer step positions at 5.0 mm spacing. The medical physicist entered 12 indexer step positions with 2.5 mm spacing and treatment was delivered. On August 14, 2003, the second fraction occurred without incident. A simulated plan was calculated on July 29, 2005, to reproduce the initial treatment plan and actual treatment delivered. The simulations suggest the patient may have received as much as 74% over dosage to a portion of his esophagus and as much as 92% under dosage to a portion of his esophagus. The patient returned to the facility on July 14, 2005, for treatment and is currently under our care. |
| Where | |
|---|---|
| Saint Vincent Hospital Indianapolis, Indiana (NRC Region 3) | |
| License number: | 13-000133-02 |
| Organization: | Saint Vincent Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+17745.92 h739.413 days <br />105.63 weeks <br />24.308 months <br />) | |
| Opened: | Edward Wroblewski 15:55 Jul 29, 2005 |
| NRC Officer: | Bill Huffman |
| Last Updated: | Jul 29, 2005 |
| 41881 - NRC Website | |
Saint Vincent Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 530402017-10-27T19:28:00027 October 2017 19:28:00
[Table view]10 CFR 35.3045(a)(1) Medical Event - Dose Misadministration ENS 418812003-07-21T06:00:00021 July 2003 06:00:00 10 CFR 35.3045(a)(1) Medical Event - Dose Both Greater than and Less than Prescribed 2017-10-27T19:28:00 | |