ML20058P727

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Partially Withheld Memo Re Staff Paper on Patient Deaths Attributed to Misadministrations
ML20058P727
Person / Time
Issue date: 12/10/1992
From: Crane P
NRC
To: Malsch M
NRC OFFICE OF THE GENERAL COUNSEL (OGC)
Shared Package
ML20058P720 List:
References
FOIA-93-178 NUDOCS 9310250183
Download: ML20058P727 (6)
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. / Q) i 1 Q. December 10, 1992 i i l HEHORANDUM FOR: Martin G. Halsch Deputy General Counsel FROH: Peter G. Crane

SUBJECT:

STAFF PAPER ON P-IENT' DEATHS ATTRIBUTED TO HISADMINISTRATIONS 101.c.,u :F lo t t p m' 0_ p r ~ ) ) 1 i 1 p I I 1 l b ) l 1 i I i* l J '3 l ] 41 k i L1 4 ~ ' ~ j p s y l 0 ~ q. i y i If l 5,, -3. t .T. 3 i. 1 'A g - D [I ?$k i d.2\\

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1 ,.9% - .gj 1 l 9; 'z - - N' 4 ,'.. ;. :.. g:.. ~ ~. t h l',^. ' l .E' o . '? u,_ _ 34. University of Massachusetts Medical Center Worcester, e lf "# C r j Hassachusetts (1987): This is yet another case of someone reading a prescription for microcuries and giving the patient 4 i

- - - ~ - i { millicurien. a thnnaand-fn1A av eda== l L1 5 i l l i 7 4 lbT.c' . gg#' I i f 3 l 58. Worcester City Hospital, Worcester, Massachusetts (1989): g,,g g This was a case in which the technologists decided that some freckles on the patient's lower back were the marks at which the j teletherapy unit should aim. The patient protested that his problem was in his upper chest, not his lower back, but the technologists went ahead and irradiated his back. N 5

l l f l0ij' f.s' j {K l l I a t l 4 D i .L 3. Baystate Medical Center, Springfield, Hassachusetts (1992): Another I-131 error, this time with 4.1 millicuries o i instead of 16 microcuries. This was the abnormal occurrence gk6 report which the NRC's consultant, Dr. Carol Marcus, bitterly protested in a !Jovember 1992 letter to Chairman Selin.. Again, { Dr. Marcus blamed the patient, who supposedly became impatient with the long wait for her diagnostic procedure. The summary states that the licensee's corrective action includes following epatient'sprogress"onceeverysixweeksforthreemonths.") l g.S i 9 , n 1 6 ) i

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SUBJECT:

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ncther 1-131 error, this time with 4.1 tillicuries i,

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