ENS 41580

v t e ENS Event
20:35 Apr 8, 2005
Title	Agreement State Report of Potential Medical Misadministration
Event Description	The following information was provided by the State of CA via e-mail (text in quotes): At 12:35 pm [the] manager of the [Saddleback Memorial Hospital] Imaging Department contacted [the CA Radiological Health Branch] to report a therapy misadministration involving HDR and Ir-192. [The hospital manager] knew few details, other than to report that the source was apparently implanted 8 cm short of its desired location. At this time it is not known how much under treatment there was to the tumor site, nor how much exposure there was to healthy tissue. [It has] not been determined if this is a CA SS&D [Sealed Source and Device]. [The hospital manager] is obtaining this information and will be reporting it back, via fax, as soon as possible. [The CA Radiological Health Branch] has requested narrative as to flow of events. This form will be updated and forwarded to NRC Ops Center as information comes in.

ENS 41580 +/-
Where
Saddleback Memorial Hospital Laguna Hills, California (NRC Region 4)
License number:	2652-30
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+-2.88 h-0.12 days <br />-0.0171 weeks <br />-0.00395 months <br />)
Opened:	Mark Pietz 17:42 Apr 8, 2005
NRC Officer:	Bill Huffman
Last Updated:	Apr 8, 2005
41580 - NRC Website
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v t e Emergency Notification System
Saddleback Memorial Hospital with Agreement State
WEEKMONTHYEAR2005-04-08T20:35:00 [Table view]
[ENS list for Saddleback Memorial Hospital]

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