ENS 45579

v t e ENS Event
05:00 Dec 15, 2009
Title	Agreement State Report - Possible Misadministration of Radioactive Medical Treatment
Event Description	The following report was received via facsimile: [Tennessee Division of Radiological Health] TN DRH was notified on 12/15/09, by the medical physicist at Cookeville Regional Medical Center, of a possible therapeutic misadministration that occurred the morning of 12/15. A patient was being treated with three sealed sources of cesium-137 (total activity of 70 mg Ra-equivalent) contained in a vaginal applicator. The patient was elderly and heavily sedated. The applicator was inserted and after twenty minutes of treatment, the nurse came into the room to check on the patient and noticed the applicator outside the treatment area. The applicator was removed and placed in a lead pig. The patient may have received a maximum dose of 76 Rem to the thigh area. A written report will be submitted by the licensee. Tennessee Report Number: TN-09-155 A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

ENS 45579 +/-
Where
Cookeville Regional Medical Center Cookeville, Tennessee (NRC Region 1)
License number:	R-71026-D10
Organization:	Tennessee Div Of Rad Health
Reporting

Agreement State
Time - Person (Reporting Time:+53.98 h2.249 days <br />0.321 weeks <br />0.0739 months <br />)
Opened:	Debra Shults 10:59 Dec 17, 2009
NRC Officer:	Dong Park
Last Updated:	Dec 17, 2009
45579 - NRC Website
v • d • e

v t e Emergency Notification System
Cookeville Regional Medical Center with Agreement State
WEEKMONTHYEAR2009-12-15T05:00:00 [Table view]
[ENS list for Cookeville Regional Medical Center]

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