ENS Event | |
|---|---|
18:00 Oct 15, 2008 | |
| Title | Overexposure to Esophagus During Medical Procedure |
| Event Description | The patient was being treated for a thyroid condition with a capsule of I-131 (150 milliCi). The procedure involved the patient swallowing the capsule to position it near the thyroid. During the procedure the capsule became lodged in the patient's throat due to an esophageal obstruction. The staff attempted to aid in passing the capsule by having the patient drink soda and eat applesauce. The capsule eventually passed the obstruction after approximately 2 1/2 hours.
The estimated dose to the esophagus was 1000 Rads. The calculated dose to the esophagus is 1786 Rads. The patient is following-up with a physician today and at that time will be notified of the overexposure. The potential adverse effects of this dose are esophagitis (inflammation of the lining of the esophagus) and radiation fibrosis. The licensee initially investigated this event shortly after it occurred and at the time contacted NRC R2 (Gabriel). At that time, based on the information that was available (mainly time the device was lodged in the patients esophagus), this event was deemed not reportable. When new information became available to the licensee the event was determined to be reportable. A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient. |
| Where | |
|---|---|
| Saint Mary'S Medical Center Huntington, West Virginia (NRC Region 1) | |
| License number: | 47-09576-01 |
| Organization: | Saint Mary'S Medical Center |
| Reporting | |
| 10 CFR 35.3045(a)(3) | |
| Time - Person (Reporting Time:+160.25 h6.677 days <br />0.954 weeks <br />0.22 months <br />) | |
| Opened: | James Norweck 10:15 Oct 22, 2008 |
| NRC Officer: | Jason Kozal |
| Last Updated: | Oct 22, 2008 |
| 44589 - NRC Website | |
Saint Mary'S Medical Center with 10 CFR 35.3045(a)(3) | |
WEEKMONTHYEARENS 445892008-10-15T18:00:00015 October 2008 18:00:00
[Table view]10 CFR 35.3045(a)(3) Overexposure to Esophagus During Medical Procedure 2008-10-15T18:00:00 | |