ENS 52470
ENS Event | |
|---|---|
08:00 Dec 23, 2016 | |
| Title | Agreement State Report - Misadministration During High Dose Rate Procedure |
| Event Description | The following information was received via facsimile:
At approximately 1355 PST on Friday, 12/30/2016, Seattle Cancer Care Alliance called the Washington State Radioactive Materials Section to report a medical event. The event had occurred on Friday, 12/23/2016 but the date that the event was discovered was not provided. The summary of the event is as follows: An Ir-192 source was incorrectly positioned during an HDR procedure, resulting in a reduced dose to the treatment volume and an unintended dose to the surrounding healthy tissue. Limited information was provided by the licensee because they are still investigating the misadministration, but additional information will be provided in a follow-up conversation on Tuesday, 1/3/2017. Washington Incident Number: WA-16-049
The following was received via email from the State of Washington: Patient was referred to SCCA [Seattle Cancer Care Alliance] for high dose rate (HDR) brachytherapy for treatment to a cervical lesion extending primarily on the left lateral side with upper to mid-vaginal involvement. Procedures were initially being developed to treat the patient with an interstitial Syed applicator. However, due to a medical condition that arose, the patient was no longer a candidate for this procedure. Therefore, the plan was to treat the patient with intracavitary brachytherapy, consisting of two fractions (1 & 2) with a tandem and ovoid (T&O) applicator set (because of a more favorable paracervical dose distribution provided by the T&O applicator configuration), and an additional two fractions (3 & 4) using the Miami cylinder applicator with tandem (to enable dose delivery to the vaginal target using the cylinder configuration). The first two tandem and ovoid (T&O) HDR treatments (fx 1 & 2) were delivered as intended on 12/19/16 and 12/21/16. During the first fraction of the Tandem/Miami cylinder applicator (fx 3) delivered on 12/23/16, an incorrect tandem applicator length (119.8 cm) was entered into the treatment planning system instead of the 131.9 cm distance for the Miami tandem. This error was not caught prior to treatment delivery and the treatment dose in the tandem was offset by 12 cm inferiorly. The error was discovered prior to the 4th fraction being delivered on 12/29/16. The patient was notified of the error and the treatment was corrected and postponed to 12/30/16. The intended dose to the cervical tumor volume for the 3rd fraction was 660 cGy, and the actual dose delivered for the fraction was 65 cGy to 90 percent of the target volume. Notified R4DO (Werner) and NMSS Events Notification via email. 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 | |
|---|---|
| Seattle Cancer Care Alliance Seattle, Washington (NRC Region 4) | |
| License number: | M0225 |
| Organization: | Wa Office Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+178.8 h7.45 days <br />1.064 weeks <br />0.245 months <br />) | |
| Opened: | Andrew Halloran 18:48 Dec 30, 2016 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Jan 17, 2017 |
| 52470 - NRC Website | |
Seattle Cancer Care Alliance with Agreement State | |
WEEKMONTHYEARENS 559462022-06-14T07:00:00014 June 2022 07:00:00
[Table view]Agreement State HDR Afterloader Motor Failure Results in Aborted Treatment ENS 524702016-12-23T08:00:00023 December 2016 08:00:00 Agreement State Agreement State Report - Misadministration During High Dose Rate Procedure 2022-06-14T07:00:00 | |