ENS 41230

v t e ENS Event
22:00 Sep 25, 2001
Title	Medical Misadministration Due to Improper Positioning of Implant Device
Event Description	Abstract - Female patient undergoing vaginal implant therapy on September 25, 2001. 'T-bomb' applicator loaded with 3 Cs-137 sources, each 19.73 mg RaEq [milligram Radium Equivalent] (49.92 mCi each, total activity 149.75 mCi). Implant performed 8:30 AM on 9/25/01. Status of implant placement made by nurse at 10:42 AM, and again at 2:10 PM. When physician checked patient at 5:00 PM on 9/25/01, implant was found outside of patient adjacent to her vaginal area. Physician did not report incident to Radiation Safety Officer, thus Licensee did not report incident to State. Estimate of total absorbed dose to the surface of the affected area was 7.55 Gy [Gray], this includes a dose of 0.74 Gy that comes from the normal implant itself. Consequence of exposure - Tissue necrosis in affected area. The cause of the misadministration is still under investigation. A contributing factor was the failure to periodically check the implant placement. The patient was informed.

ENS 41230 +/-
Where
North Shore Medical Center Salem, Massachusetts (NRC Region 1)
License number:	44-0161
Organization:	Ma Radiation Control Program
Reporting

Agreement State
Time - Person (Reporting Time:+27855.12 h1,160.63 days <br />165.804 weeks <br />38.156 months <br />)
Opened:	Robert Gallaghar 14:07 Nov 29, 2004
NRC Officer:	Steve Sandin
Last Updated:	Nov 29, 2004
41230 - NRC Website
v • d • e

v t e Emergency Notification System
North Shore Medical Center with Agreement State
WEEKMONTHYEAR2001-09-25T22:00:00 [Table view]
[ENS list for North Shore Medical Center]

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