ML20042E121
| ML20042E121 | |
| Person / Time | |
|---|---|
| Issue date: | 03/26/1990 |
| From: | Davis A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | Silberstein E CINCINNATI, UNIV. OF, MEDICAL CENTER, CINCINNATI |
| References | |
| NUDOCS 9004200159 | |
| Download: ML20042E121 (1) | |
Text
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' MAR 2 6 1990 Edward B. 811berstein, M.D.
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Ur.ig re y of Cincinnati Hospitals
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234 boodman Street Cincinnati, OH 45267-0577 i
Dear Dr. S11berstein:
This letter is'to confirm the telephone. conversation of March 19. 1990,-
between you and Mr. Roy J. Cantano of my staff.= In that conversation, you, _
agreed.that you will assist this office by serving as a medical consultant to evaluate the exposure to a patient involved in the misadministration described in the enclosed Preliminary Notification dated March 20, 1990.
-)
It is our understanding that you will-evaluate _the findings'and determine if the misadministration could cause any significant long term biological
~
effects, and if the patient is receiving. proper-followup medical care.
t Mr. Caniano has informed Mr.: Terry Dillon, Medical Physicist i'or St. Mary's Hospital, that you will be reviewing this eventLand~will be contacting him..
t He can be reached at (517) 776-8115.
A report of your findings and conclusions should be provided within 30 days of the completion of your investigatory and advisory effort.
Thank you for your assistance.in this matter..Should you have any questions; i
please contact Mr. Caniano who is the regional contact for this. investigation at (708) 790-5721.
Sincerely,
' Orishal. M g:s 4 9
, b ECs U U10 A. Bert Davis
(
Regional Administrator.'
t
Enclosure:
Preliminary Notification dtd 03/20/90 t
p cc'w/ enclosure:
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License File No. 21-03646-04 0
9004200159 900326
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REG 3 LIC30 21-03646-04 PDC
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Enclo:urs PRELIf0NARYNOTIFICATIONOFEVENTORUNUSUALOCCURRENCEPHO-III-90-20DhtsM:rch 20, 1990 s
e l-Thio preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public interost significance. The information is as initially received without verification or cyclustion, and is basically all that is known by the Region III staff on this date.
Fccility:
St. Mary's Hospital Licensee Emergency Saginaw, Michigan Classification:
Unusual Event License No. 21-03646-04 Alert Site Area Emergency General Emergency I Not Applicable I
Subject:
THERAPEUTIC HISADMINISTRATION On March 19, 1990, the licensee reported that a 46-year-old patient received a therapeutic.
j redistion dose to a portion of her spine not planned for treatment.
l Thi patient was scheduled to receive thirteen 250-tad treatments to the lumbar portion of the
- pins using a cobalt-60 teletherapy unit. The-patient had previously received a series of trostments totalling 4,500 rads to the thoracic portion of the spine in December 1988.
In this instance, the technician failed to consult the treatment chart prior to administering th2 treatment and instead used an anatomical marker still present on the skin from the oorlist series of treatments for treatment set up.
The treatment dose was therefore given to tha thoracic area.
-a Th3 licensee has a policy requiring a second technician to verify the treatment area prior to cdninistering treatments, but this policy was not followed.
Tha licensee does not expect any short-term adverse medical effects as a result of the Orrer. When the error was discovered, the initial treatment was repeated to the correct l
aros of the spine. The patient's physician was informed of the error.
Region III (Chicago) has retained a medical consultant' to evaluate the effects of the incidsnt. Region III will conduct a special inspection to review the circumstances of the misedninistration.
t Tha State of Michigan has been notified. The information in this preliminary notification h:s bzen reviewed with licensee management.
1 R:gion III received initial notification of this incident from the licensee at 10:30 a.m.
(CST) on March 19, 1990. Additional information was subsequently obtained. This nstification is current as of 10:00 a.m., March 20, 1990.
t#0' CONTACT:
R. Caniano (FTS 388-5721)
B. Mallett (FTS 388-5612)
DISTRIBUTION:
HEADQUARTERS OFFICES REGIONS MAIL TO:
Chairman Carr NMSS Region I DCS (Orig)
Comm. Roberts CPA:SLITP Region II DOT (Trans.
Comm. Rogers GPA:PA Region IV Only)
Comm. Curtiss GPA:C4 Region V Comm. Remick
- 01G j
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- ASLAP FAX TO:
omu_.
Gen. Counsel Research INPO /137 NSAC LIC
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NRR IRM NRC OPS CTR AEOD ACRS PDR (8/634-3343)
Enforcement
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CDenotes a Displaywriter/PC not an IBM 5520 Terminal.
Rev. 12/05/89