NRC Information Notice 2009-17: Reportable Medical Events Involving Treatment Delivery Errors Caused by Confusion of Units for the Specification of Brachytherapy Sources

Dear Medical Use Licensee:

The NRC has issued the attached Information Notice 2009-17 to alert brachytherapy use licensees about treatment delivery errors and associated medical events caused by confusion of units for the specification of low-energy photon-emitting brachytherapy sources implanted into patients. These events illustrate the following three main areas of concern:

1. data entry error, whereby the source strength was entered into a computerized treatment planning system in units not used by the system;
2. ordering error, whereby sources of an incorrect source strength were delivered and used because either the licensee or the manufacturer made an error in the requested units; and,
3. conversion error, whereby a conversion between two different units was omitted or performed incorrectly.

This notice discusses procedures for independent confirmation of key processes, a system of redundant checks and reviews of the treatment plan. If you have any questions, please contact our office at (217) 785-9947.