Database of radiological incidents and related events--Johnston's Archive

South Bend radiotherapy accident, 2004

compiled by Wm. Robert Johnston
last modified 1 November 2007

Date: 26 January - 22 March 2004

Location: St. Joseph Regional Medical Center, South Bend, Indiana, United States

Type of event: radiotherapy accident


Three women received localized overdoses during brachytherapy using cesium-137 sources. The brachytherapy applicator was loaded with sources of the incorrect size, allowing the sources to migrate from the intended position and cause localized doses to the skin of the upper thigh of 2,000, 2,000, and 1,500 rad, respectively. All three patients developed skin lesions on the inner thigh after two weeks.

Consequences: 3 injuries


© 2007 by Wm. Robert Johnston.
Last modified 1 November 2007.
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