U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
08/26/2002 - 08/27/2002
** EVENT NUMBERS **
39141
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 39141 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: WA DIVISION OF RADIATION PROTECTION |NOTIFICATION DATE: 08/21/2002|
|LICENSEE: PROVIDENCE EVERETT MEDICAL CENTER |NOTIFICATION TIME: 15:02[EDT]|
| CITY: EVERETT REGION: 4 |EVENT DATE: 08/19/2002|
| COUNTY: STATE: WA |EVENT TIME: [PDT]|
|LICENSE#: WN-M0135-1 AGREEMENT: Y |LAST UPDATE DATE: 08/21/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |WILLIAM JOHNSON R4 |
| |DOUG BROADDUS NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: TERRY C. FRAZEE (e-mail) | |
| HQ OPS OFFICER: MIKE NORRIS | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT INVOLVING MEDICAL MISADMINISTRATION |
| |
| "The licensee reported that a patient received 2640 cGy (rad) during a |
| cardiac intravascular brachytherapy treatment instead of the intended 2000 |
| cGy (rad), a 32% overexposure. The patient was being treated with the |
| Guidant Corporation Galileo intravascular brachytherapy high dose rate |
| remote afterloader device (serial #27958502) with a model GDT-P32-2 source |
| wire (serial #020807016) containing 4.44 GBq (119.9 [millicuries]) of P-32 |
| at time of treatment. The patient's vessel size was larger than the |
| automatically calculated maximum diameter treatment. A manual calculation |
| of dwell time was required, based on the dose rate tables available in the |
| Guidant Manual (section 6.13 table 5). However, the dose rate for a 4.6 mm |
| diameter (3.30 mm treatment depth) was inadvertently used instead of 4.05 mm |
| diameter (3.03 mm treatment depth). This resulted in a delivered dose of |
| 2640 cGy (rad) at 3.03 mm. The cause of the event is human error. The |
| licensee's corrective action is to have a second independent calculation |
| performed by Physics and Dosimetry staff prior to treatment whenever a |
| manual calculation using the dose rate tables is necessary. No adverse |
| consequences are expected. The referring physician and the patient were |
| notified of the overexposure." |
+------------------------------------------------------------------------------+