Case 0005: Received Dose Greater than Prescribed Dose

The patient received SAVI (Strut-Adjusted Volume Implant) High Dose Rate Treatments on two separate dates. After the second treatment, it was noted that the dwell time on one catheter appeared unusual. The first treatment 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 treatment plan from the first treatment and reached the same conclusion, that the catheter had been mislabeled.

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

This event summary was taken directly from the NRC website.

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