ENS 54906
ENS Event | ||
|---|---|---|
05:00 Sep 22, 2020 | ||
| Title | Agreement State Report - Medical Event | |
| Event Description | The following information was received via email from the Illinois Emergency Management Agency (The Agency):
The Agency was notified on 9/23/20 that a high dose rate afterloader (HDR) administration resulted in a medical event on 9/22/20 at the Western Illinois Cancer Treatment Center in Galesburg, IL. The licensee states no untoward effects are expected of the patient. Agency staff will respond and evaluate on 9/24/20. The Agency was contacted by an authorized medical physicist and radiation safety officer for Western Illinois Cancer Treatment Center in Galesburg (RML IL-01902-01), to report a medical event that occurred the previous day on September 22, 2020. Reportedly, a patient was prescribed a 30 Gy therapeutic dose to the vaginal cuff, to be delivered over a series of (5) fractionated 6 Gy administrations. Two of the 6 Gy administrations had already been performed on 9/15/20 and 9/18/20 without issue. The patient arrived for the third fractionated dose of 6 Gy on 9/22/20. An unnamed nurse was present as well. It is unclear if an authorized medical physicist was physically present at time of administration. Rather than delivering the dose through the vaginal cavity, the HDR applicator was inserted into the rectal cavity. This was not noticed until after the treatment was delivered. Based on the information currently available, the written directive specified a 6 Gy fraction to be delivered to the vaginal treatment area. The dose delivered was 1.46 Gy. This meets the reportable criteria in 32 Ill. Adm. Code 335.1080(a)(1) for an underdose. Additionally, had the administration gone as prescribed; the rectum would have only received (for 50% of the volume) 1.53 Gy per fraction. In this administration, the dose to the rectum (50% of volume) was 3.94 Gy. This also meets the reportable criteria for an overexposure. The format of this report provides data in the context of an overexposure. The language in the written directive will be reviewed, as well as procedures, personnel present, treatment plan and post-plan calculations on September 24, 2020. Reporting timeliness appears appropriate at this time. A written report will be required to the Agency by October 7, 2020. The referring physician has been notified. The patient is being advised today, which at this time appears to be in accordance with applicable regulations. This report will be updated as additional information becomes available. Illinois Item Number: IL200017. 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 | |
|---|---|
| Illinois Emergency Mgmt. Agency Galesburg, Illinois (NRC Region 3) | |
| License number: | IL-01902-01 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+33.97 h1.415 days <br />0.202 weeks <br />0.0465 months <br />) | |
| Opened: | Gary Forsee 14:58 Sep 23, 2020 |
| NRC Officer: | Brian Lin |
| Last Updated: | Sep 23, 2020 |
| 54906 - NRC Website | |
Illinois Emergency Management Agency with Agreement State | |||
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