Event Notification Report for December 14, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/13/2003 - 12/14/2003
EVENT NUMBERS
42359
General Information or Other
Event Number: 42359
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT DISCLOSED BY STATE LAW
Region: 1
City: State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: R. DANSEREAU (via fax)
HQ OPS Officer: STEVE SANDIN
Licensee: NOT DISCLOSED BY STATE LAW
Region: 1
City: State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: R. DANSEREAU (via fax)
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/22/2006
Notification Time: 15:25 [ET]
Event Date: 12/14/2003
Event Time: 00:00 [EST]
Last Update Date: 02/22/2006
Notification Time: 15:25 [ET]
Event Date: 12/14/2003
Event Time: 00:00 [EST]
Last Update Date: 02/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
PAMELA HENDERSON (R1)
GREG MORELL (NMSS)
PAMELA HENDERSON (R1)
GREG MORELL (NMSS)
AGREEMENT STATE REPORT INVOLVING A MEDICAL MISADMINISTRATION
The following information was received via facsimile:
"NY-06-002
"HDR Brachytherapy medical event (NYS DOH Internal Tracking; No. 13)
"New York law prohibits the release of any identities in cases of medical events. Therefore the facility name, etc., is not contained in this report.
"RSO reported a medical misadministration involving a female patient treated on 5/12-14/2003 with SYED(needles)/HDR (Varian unit). Apparently there was an error, with respect to the area treated (incorrect dwell positions), which was not discovered until a final chart review. The treatment plan and double check of the calculations were performed as required. A different physicist than the one who did the treatment plan and double checks discovered the error. The facility submitted a written report. According to the report, since the original catheters had been discarded, reconstructing the scenario to the best of their ability, they concluded that all catheters and connecting tubes had the same lengths as previous similar implants. The measurement of 4 catheters on the first implant day obtained a catheter length of 119.8 cm. It was not repeated for the other 7 catheters and not double-checked by measurement by another physicist. However, the number, 119.8 cm is different from what they usually get for this type of procedure. Therefore, they concluded that the error occurred at this stage of the planning: i.e., (1) the planner did not verify that numbers were similar to what they usually get. (2) physics double check prior to the procedure did not include a second measurement nor did it check if the numbers were reasonable. The measurement was incorrect. Their corrective actions, if followed strictly, should prevent this error from happening again.
"Target (Tumor) Intended 2000 cGy. Delivered 150 cGy.
"Normal Tissue Expected 150 cGy. Delivered 2000 cGy.
"The patient was seen by her gynecological oncologist. This physician and the radiation oncologist determined that the patient should not be adversely affected because the dose was within tolerance of tissue including those of the vagina, rectum and bladder. However they were concerned that the tumor bed did not receive an adequate radiotherapy dose. The patient received additional low dose brachytherapy treatment. The LDR was given on 6/27/03, 1200 cGy to 0.5 cm from the cylinder surface. This treatment was delivered as intended."
The following information was received via facsimile:
"NY-06-002
"HDR Brachytherapy medical event (NYS DOH Internal Tracking; No. 13)
"New York law prohibits the release of any identities in cases of medical events. Therefore the facility name, etc., is not contained in this report.
"RSO reported a medical misadministration involving a female patient treated on 5/12-14/2003 with SYED(needles)/HDR (Varian unit). Apparently there was an error, with respect to the area treated (incorrect dwell positions), which was not discovered until a final chart review. The treatment plan and double check of the calculations were performed as required. A different physicist than the one who did the treatment plan and double checks discovered the error. The facility submitted a written report. According to the report, since the original catheters had been discarded, reconstructing the scenario to the best of their ability, they concluded that all catheters and connecting tubes had the same lengths as previous similar implants. The measurement of 4 catheters on the first implant day obtained a catheter length of 119.8 cm. It was not repeated for the other 7 catheters and not double-checked by measurement by another physicist. However, the number, 119.8 cm is different from what they usually get for this type of procedure. Therefore, they concluded that the error occurred at this stage of the planning: i.e., (1) the planner did not verify that numbers were similar to what they usually get. (2) physics double check prior to the procedure did not include a second measurement nor did it check if the numbers were reasonable. The measurement was incorrect. Their corrective actions, if followed strictly, should prevent this error from happening again.
"Target (Tumor) Intended 2000 cGy. Delivered 150 cGy.
"Normal Tissue Expected 150 cGy. Delivered 2000 cGy.
"The patient was seen by her gynecological oncologist. This physician and the radiation oncologist determined that the patient should not be adversely affected because the dose was within tolerance of tissue including those of the vagina, rectum and bladder. However they were concerned that the tumor bed did not receive an adequate radiotherapy dose. The patient received additional low dose brachytherapy treatment. The LDR was given on 6/27/03, 1200 cGy to 0.5 cm from the cylinder surface. This treatment was delivered as intended."