Event Notification Report for February 07, 2012

AGREEMENT STATE REPORT - PATIENT RECEIVED DOSE LESS THAN INTENDED

The following was received from the state of New Jersey via email:

"A patient was treated with a Varian VariSourceTM HDR unit on February 7, 2012. The prescription dose was 200 cGy per fraction for 8 fractions. The first two fractions were delivered to the patient with a fractional dose of 25 cGy instead of the prescribed fractional dose of 200 cGy before the discovery of the event around 7 p.m. on February 7, 2012. The initial treatment plan was designed for a single fractional dose of 200 cGy and was approved on screen by the physician. The plan was later modified to 8 fractions with a fractional dose of 200 cGy before the delivery of the first fraction. This modification was however done incorrectly and the isodose line of 200 cGy, instead of 1600 cGy, was planned to cover the target volume. [Isodose means a radiation dose of equal intensity to more than one body area.] Two fractions of treatment (out of a planned 8) were delivered on 2/7/2012 before discovery of the event, resulting in a dose of 25 cGy per fraction (instead of 200 cGy) prescribed to the target volume."


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.

BROKEN SHUTTER CABLE ON FIXED PROCESS GAUGE

While closing a the shutter on a Thermo Fisher Model 5197 gauge containing 100 milliCuries of Cs-137, the operating cable broke. There were no personnel exposures. The gauge shutter is currently shut. The licensee is contacting the manufacturer to arrange for repair.