ENS 53071
ENS Event | |
|---|---|
05:00 Nov 6, 2017 | |
| Title | Agreement State Report - Dose Greater than 50 Rem Delivered at a Site Not Intended for Treatment |
| Event Description | The following report was received from the Ohio Department of Health via email:
On Friday, November 10, 2017, ODH [Ohio Department of Health] received notification that a cancer patient may have received a dose greater than 50 rem at a site not intended for treatment. A follow-up call was made on Monday November 13, 2017. The licensee stated they believe the Elekta Flexitron (model 136149A02) remote afterloader software package used an incorrect catheter model during the first treatment fraction. The error was discovered while preparing the second fraction. ODH will be sending an inspector to investigate the event this week. See licensee initial description below: A patient was planned to be treated with HDR [High Dose Rate] brachytherapy for GYN [Gynocology] cancer with three fractions. The HDR treatment was planned with a single curved catheters through a Tandem and Cylinder. A dosimetrist preformed a CT based treatment plan for the first fraction. During planning, the dosimetrist did not digitize the catheter correctly. A physicist checked the HDR plan in a hurry and failed to detect the incorrect reconstructed catheter shape in the planning software. During the treatment delivery, the delivery system translated the incorrectly reconstructed catheter as a linear catheter, resulting in the treatment length from the intended 9.0 cm to 15.7 cm. On the second fraction, a new plan was created based on the CT of the day. The dosimetrist did the digitization correctly this time. During the planning check (a routine process), the physicist noticed the differences between the two plans and discovered the error on the first fraction treatment. Remote afterloader HDR Device: ELEKTA Model Number: 136149A02 Sealed Source Brachytherapy Source: IR-192 Model Number: 136147 Ohio Event Number: OH170008 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 | |
|---|---|
| Akron General Medical Center Akron, Ohio (NRC Region 3) | |
| License number: | 02120780000 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+203.28 h8.47 days <br />1.21 weeks <br />0.278 months <br />) | |
| Opened: | Michael J. Rubadue 16:17 Nov 14, 2017 |
| NRC Officer: | Jeff Herrera |
| Last Updated: | Nov 14, 2017 |
| 53071 - NRC Website | |
Akron General Medical Center with Agreement State | |
WEEKMONTHYEARENS 530712017-11-06T05:00:0006 November 2017 05:00:00
[Table view]Agreement State Agreement State Report - Dose Greater than 50 Rem Delivered at a Site Not Intended for Treatment ENS 519802016-04-26T04:00:00026 April 2016 04:00:00 Agreement State Agreement State Report - Missing Source ENS 519792016-04-21T04:00:00021 April 2016 04:00:00 Agreement State Agreement State Report - Missing Source ENS 488392013-03-19T04:00:00019 March 2013 04:00:00 Agreement State Agreement State Report - Y-90 Sir-Sphere Under Dose of 87% ENS 486782013-01-15T05:00:00015 January 2013 05:00:00 Agreement State Agreement State Report - Misplacement of Brachytherapy Source During Medical Treatment ENS 431922006-09-27T05:00:00027 September 2006 05:00:00 Agreement State Agreement State Report - Potential Medical Event ENS 427292006-07-10T04:00:00010 July 2006 04:00:00 Agreement State Agreement State Report - Medical Overdose 2017-11-06T05:00:00 | |