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Event Notification Report for January 30, 2012

U.S. Nuclear Regulatory Commission Operations Center Event Reports For 01/27/2012 - 01/30/2012 ** EVENT NUMBERS ** 47616 Agreement State Event Number: 47616 Rep Org: NC DIV OF RADIATION PROTECTION Licensee: PRESBYTERIAN HOSPITAL Region: 1 City: CHARLOTTE State: NC County: License #: 060-0019-6 Agreement: Y Docket: NRC Notified By: HENRY BARNES HQ OPS Officer: STEVE SANDIN Notification Date: 01/23/2012 Notification Time: 16:42 [ET] Event Date: 01/05/2012 Event Time: [EST] Last Update Date: 01/23/2012 Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE Person (Organization): GLENN DENTEL (R1DO) BRUCE WATSON (FSME) Event Text AGREEMENT STATE REPORT - MEDICAL RADIATION TREATMENT EXPOSURE TO WRONG TREATMENT SITE The following report was received from the State of North Carolina via email: "A cancer patient undergoing therapeutic radiation treatment for gastric cancer received an exposure to the wrong treatment site. This error occurred using a HDR afterloader device with a radioactive source containing Ir-192. "The event occurred after the dosimetrist made an error while correcting a change to dwell position due to catheter migration. The dwell position was mistakenly adjusted out rather than in. Two treatments were made prior to the error being detected. "The error resulted in an approximately 4 cm positioning error, which caused the source to stop short of the target so that the total prescribed dose was not delivered. "The patient was informed of the event, and received a correct third treatment as well as external beam therapy. "Additional information will be provided as it is provided by the licensee." The intended treatment site was a bile duct which was to receive 700 cGy in three (3) fractions. The first two (2) fractions were delivered on 1/5/2012 and 1/12/2012 with the source mispositioned as indicated above. The Regional Inspector for the State of NC is following up. 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.

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