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Event Notification Report for February 7, 2018

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Event Reports For
02/06/2018 - 02/07/2018

** EVENT NUMBERS **


53187

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Non-Agreement State Event Number: 53187
Rep Org: MISSOURI BAPTIST MEDICAL CENTER
Licensee: MISSOURI BAPTIST MEDICAL CENTER
Region: 3
City: ST. LOUIS State: MO
County:
License #: 24-11128-02
Agreement: N
Docket:
NRC Notified By: AMY ETTLING
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/29/2018
Notification Time: 17:20 [ET]
Event Date: 01/29/2018
Event Time: 09:30 [CST]
Last Update Date: 01/29/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
BILLY DICKSON (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

RECEIVED DOSE GREATER THAN PRESCRIBED DOSE

A patient received SAVI (Strut-Adjusted Volume Implant) High Dose Rate Treatments on January 26, 2018 and January 29, 2018. After the treatment, it was noted that the dwell time on one catheter appeared unusual. The treatment from January 26 was then reviewed and it was discovered that the catheters were labeled incorrectly during the initial treatment planning process. The physician was notified to review the delivered dose. Another physicist was contacted and remotely viewed the delivered treatment of the January 29 treatment as well as the treatment plan from January 26. This physicist came to the same conclusion that the catheters had been mislabeled on the January 26 CT scan.

The skin received a greater dose than intended for one delivered fraction. 1cc received 848cGy, intended 256cGy and 0.1cc received 1500cGy, intended 282cGy. A decision was made by the physician to cancel all further radiation treatments using the SAVI device and the catheter was removed. The patient was notified of the event, as well as the referring physicians.

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.

Page Last Reviewed/Updated Wednesday, February 07, 2018
Wednesday, February 07, 2018