Event Notification Report for August 18, 2004
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/17/2004 - 08/18/2004
EVENT NUMBERS
40971
General Information or Other
Event Number: 40971
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: PROVIDENCE ST. JOSEPH MEDICAL CENTER
Region: 4
City: BURBANK State: CA
County:
License #: CA0059-19
Agreement: Y
Docket:
NRC Notified By: K. KAUFMAN
HQ OPS Officer: JOHN MacKINNON
Licensee: PROVIDENCE ST. JOSEPH MEDICAL CENTER
Region: 4
City: BURBANK State: CA
County:
License #: CA0059-19
Agreement: Y
Docket:
NRC Notified By: K. KAUFMAN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/20/2004
Notification Time: 18:41 [ET]
Event Date: 08/18/2004
Event Time: 12:00 [PDT]
Last Update Date: 08/20/2004
Notification Time: 18:41 [ET]
Event Date: 08/18/2004
Event Time: 12:00 [PDT]
Last Update Date: 08/20/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GREG PICK (R4)
GARY JANOSKO (NMSS)
GREG PICK (R4)
GARY JANOSKO (NMSS)
AGREEMENT STATE REPORT- THERAPEUTIC MISADMINISTRATION
Therapeutic misadministration from HDR [High Dose Rate brachytherapy]. Patient was scheduled for three HDR retreatments for cancer between the urethra & bladder wall. The treatment dose/fraction was supposed to be 300 cGy [centiGray] to a 7 mm radius distance from the source, & the length of the treatment plan was 3 cm. They used a Varian catheter & measuring wire. When they inserted the measuring wire, they thought they were at the end of the catheter, but they were actually about 20 cm short. The source for two treatments, on August 18 and 19, was actually located about 10 cm from the end of the penis, exterior to the body. They estimate the tumor site only got about 10 cGy, and the penis may have received approximately the same dose it would have received had the source been inserted into the correct location. The root cause appears to be an error on the part of the medical physicist. The patient is 93 years old, and both the radiation oncologist and the primary care physician believe he should not be told. The third treatment was performed correctly, and they have scheduled him for two additional treatments. They believe there will be no impact on the patient.
Therapeutic misadministration from HDR [High Dose Rate brachytherapy]. Patient was scheduled for three HDR retreatments for cancer between the urethra & bladder wall. The treatment dose/fraction was supposed to be 300 cGy [centiGray] to a 7 mm radius distance from the source, & the length of the treatment plan was 3 cm. They used a Varian catheter & measuring wire. When they inserted the measuring wire, they thought they were at the end of the catheter, but they were actually about 20 cm short. The source for two treatments, on August 18 and 19, was actually located about 10 cm from the end of the penis, exterior to the body. They estimate the tumor site only got about 10 cGy, and the penis may have received approximately the same dose it would have received had the source been inserted into the correct location. The root cause appears to be an error on the part of the medical physicist. The patient is 93 years old, and both the radiation oncologist and the primary care physician believe he should not be told. The third treatment was performed correctly, and they have scheduled him for two additional treatments. They believe there will be no impact on the patient.