ENS 53516
ENS Event | |
|---|---|
07:00 Jul 17, 2018 | |
| Title | Agreement State Report - Received Dose Greater than Prescribed Dose |
| Event Description | The following information was obtained from the state of California via email:
A cervical patient was receiving her first High Dose Rate (HDR) brachytherapy treatment, using the Varian VariSource iX HDR, on Tuesday, July 17, 2018, starting at 10 am [PDT]. The patient's 3 applicators, for the tandem and right/left ovoids, were attached to the distal ends of the transfer guide tubes specially coded for the GYN treatments (using the Varian Quick Fit connectors), with the tandem as channel 1, ovoid right as channel 2 and ovoid left as channel 3. The guide tubes were attached by the radiation therapist, and checked by two other employees. After the first fraction, the radiation therapist was preparing to disconnect the guide tubes from the applicators and noted that the distal end of the transfer guide tube for channel 1 was hanging approximately vertically along the end of the gurney. The physicist also verified this, and that the Quick Fit connectors for all of the guide tubes were still secured to the applicator and locked in place with their locking rings. However, it appeared that the transfer tube for channel 1 had been severed at its distal end from its Click Fit connector. The patient was re-surveyed to confirm that the source had retracted appropriately, with no radiation detected within the patient. The radiation therapist proceeded to disconnect the guide tubes from the applicators, remove the applicators from the patient, and clean the patient up for discharge home. The licensee is unable to ascertain whether the tube failed before the Ir-192 source deployed to the treatment site or upon return of the source to HDR storage. It is possible that the patient received the planned treatment, with the source in the correct dwell locations. It is also possible that the Ir-192 seed landed on the gurney close to the patient's skin, or that the source extended vertically down from the distal end of the transfer tube, in which case the patient's lower extremities were exposed to a smaller dose of approximately 500 mR. Staff immediately notified Varian of the event, and took the tubing out of service. New tubing is scheduled to arrive on Friday 7/20/2018, and no HDR treatments will occur before then. Staff also immediately notified the patient's physician. RHB will conduct a site visit on Friday 7/20/2018. California report no.: 5010-071718 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 | |
|---|---|
| Providence Saint Joseph Medical Center Burbank, California (NRC Region 4) | |
| License number: | 0059-19 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+43.07 h1.795 days <br />0.256 weeks <br />0.059 months <br />) | |
| Opened: | Thomas Geza Miko 02:04 Jul 19, 2018 |
| NRC Officer: | Brian Lin |
| Last Updated: | Jul 19, 2018 |
| 53516 - NRC Website | |
Providence Saint Joseph Medical Center with Agreement State | |
WEEKMONTHYEARENS 535162018-07-17T07:00:00017 July 2018 07:00:00
[Table view]Agreement State Agreement State Report - Received Dose Greater than Prescribed Dose 2018-07-17T07:00:00 | |