Database of radiological incidents and related events--Johnston's Archive
Houston radiotherapy accident, 2003
compiled by Wm. Robert Johnston
last modified 22 October 2008
9-11 June 2003
Saint Joseph's Hospital, Houston, Texas, United States
Type of event:
A cancer patient undergoing radiation treatment for breast cancer received a large localized skin dose due to incorrect source placement. The source, in a high dose-rate afterloader, was placed 20 cm from the catheter tip instead of 20 mm from the tip during treatments on 9, 10, and 11 June. The error was attributed to human error in entering the treatment plan into the device control console following an initial QA test; improvements to the device control system were also recommended. The patient received a 7,000 rad dose to a skin area 1 cm in diameter, resulting in erythema after two weeks. The erythema did not heal and the ulceration was surgically removed, after which it healed in two months.
© 2007, 2008 by Wm. Robert Johnston.
Last modified 22 October 2008.
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