ENS 47579

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v t e ENS Event
07:00 Jan 5, 2012
Title	Medical Underexposure to Target Area Using High Dose Rate Afterloader Device
Event Description	The licensee reported that a patient received only about 10% of the required dose to the target area during a treatment for esophageal cancer. The prescribed dose for the esophageal region was 700 centigray. The area was being treated with a Varian High Dose Rate Brachytherapy Afterloader device using a 6.344 Curie Ir-192 source. The location of the source is normally tracked by a radiographically opaque image near the source. In this case, the end of the catheter also appeared somewhat radiographically opaque and was mistaken for the source location. Consequently, the source was mispositioned about 4 cm back from the intended target area resulting in the underexposure. The physician and patient have been notified and no health effects are anticipated from the area that was unintentionally exposed due to the mispositioning of the source. * * UPDATE AT 1345 EST ON 01/18/12 FROM KARI CANN TO S. SANDIN * * * The licensee is continuing their review of this incident and have determined that the source may have been mispositioned by as much as 29 cm back from the intended target area. This may have resulted in excessive exposure to portions of the upper neck and back of the patient. A physician has scheduled an anatomical examination of the patient tomorrow to assess if there are any adverse effects related to the treatment. NRC Region IV Inspectors are currently on-site. Notified R4DO (Pick) and FSME (McIntosh). 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.

ENS 47579 +/-
Where
Benefis Health Care Great Falls, Montana (NRC Region 4)
License number:	25-12710-01
Organization:	Benefis Health Care
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+105 h4.375 days <br />0.625 weeks <br />0.144 months <br />)
Opened:	Kari Cann 16:00 Jan 9, 2012
NRC Officer:	Bill Huffman
Last Updated:	Jan 18, 2012
47579 - NRC Website
v • d • e

v t e Emergency Notification System
Benefis Health Care with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2012-01-05T07:00:00 [Table view]
[ENS list for Benefis Health Care]

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