ENS 48389
ENS Event | |
|---|---|
07:00 May 23, 2012 | |
| Title | Agreement State Report - Potential Medical Event |
| Event Description | The following was received from the State of California:
During a routine inspection on Oct. 8, 2012, RHB inspectors discovered a potential medical event had occurred on May 23, 2012. A patient was admitted to the hospital for carcinoma treatment of the endometrium near both ovaries on May 22, 2012 and treatment began at 1800 PDT. The treatment plan called for 3000 cGy to each ovary, using two 18.5 mg Ra eq. CS-137 sources and an ovoid applicator. [The] dosimetrist placed one source at a time into an insert, which was to be verified by the physician, a second year medical resident, who then placed the insert into the applicator and patient. The source inserts are individually screwed into the ovoid applicator, which prevents the source from movement. The patient treatment was to take 26.5 hrs. On May 23, 2012 at 2030, [the doctor] and the dosimetrist were removing the implant from the patient, starting with the right side. That source was verified to be in the insert and then placed into the pig. The doctor then proceeded to remove the left side insert, which was handed to the dosimetrist, who found the insert to be empty. The radiation survey meter was used immediately around the patient, rolling her back and forth as it appeared the source may be on the bed somewhere. The source was found on an IV monitor stand, which was approx. 2 foot from the patients head partially blocked by a portable lead shield that had been placed the day before. The source recovery was completed around 2045. Hospital staff (supervising MD, lead dosimetrist and RSO) were notified of the event and the patient treatment of the left side was completed on May 29, 2012, after revising the original patient treatment plan. The investigation did not discover how the source ended up on the IV stand. The licensee's RSO evaluated the event and did not feel that it qualified as a medical event per 10CFR35.3045 and therefore did not inform RHB within the 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> timeframe. 5010 #: 052312 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. |
| Where | |
|---|---|
| Loma Linda Medical Center San Bernadino, California (NRC Region 4) | |
| License number: | 0060-36 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+3344.25 h139.344 days <br />19.906 weeks <br />4.581 months <br />) | |
| Opened: | Donald Oesterle 15:15 Oct 9, 2012 |
| NRC Officer: | Charles Teal |
| Last Updated: | Oct 25, 2012 |
| 48389 - NRC Website | |
Loma Linda Medical Center with Agreement State | |
WEEKMONTHYEARENS 550842021-01-25T08:00:00025 January 2021 08:00:00
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