EN Revision Imported Date : 7/22/2020
EN Revision Text: AGREEMENT STATE REPORT - SUSPECTED DOSE TO WRONG ORGAN
The following is a summary of email received from the Oklahoma Department of Environmental Quality (OK DEQ):
OK DEQ was just informed that yesterday, June 23, 2020, a medical event may have occurred involving a patient undergoing radiation therapy to the vagina. The treatment plan called for three (3) fractions delivered by a High Dose Rate (HDR) afterloader. After the first fraction was administered, the therapist noted the presence of fecal matter on the applicator. The licensee is assuming that the applicator was placed in the patient's rectum instead of the vagina. The treatment plan estimated a dose of 0.85 Sv to the rectum due to the procedure. The licensee estimates the actual dose delivered, assuming the applicator was in the rectum, to be 1.5 Sv. The licensee is the University of Oklahoma Health Science Center, OK-03176-01. This is a Type A medical broadscope license. OK DEQ will provide more information as it becomes available.
* * * UPDATE ON 07/21/2020 AT 1549 EDT FROM LIBBY MCCASKILL TO OSSY FONT * * *
The following update was received from the OK DEQ via email:
OK DEQ is correcting the licensee name and license number. Initially, they were reported as the University of Oklahoma Health Science Center, OK-03176-01. The correct licensee is OU Medicine, Inc., License No. OK-21035-01.
Notified R4DO (Drake) and NMSS Event Notification via email.
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.