ML20071L561
| ML20071L561 | |
| Person / Time | |
|---|---|
| Site: | 05000392 |
| Issue date: | 03/03/1983 |
| From: | Roe G OHIO STATE UNIV., COLUMBUS, OH |
| To: | Bergin B NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| Shared Package | |
| ML20071L457 | List: |
| References | |
| NUDOCS 8305270591 | |
| Download: ML20071L561 (3) | |
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- The Ohio State University notitation Snfoty D 042 Graves liall
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333 West 10th Avenue Coluenbus, Ohio 43210
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Mr. Bob Bergin U.S. Nuc1 car Regulat ory Co.uission 3y,gg]
08 Region III 799 Roosevelt Road Glen Ellyn, Ill.
60137
Dear Mr. Bergin:
Enclosed is an information report concerning a therapy misadoiinistration as defined by 10 CFR 35.42.
Telephone notification was made at 3:30 P.M. on February 18, 1983.
If I can be of further assistance, or provide additional information, please call.
Sincerely, L
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'Ge e B. Roe -
Assistant Director Office of Radiation Safety GBR:1p Enclosure cc: Walter Carey, Ph.D.
Jo Nell Pohl, Dosimetrist Frank Batley, M.D.
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MAR 171985 Wn 8305270591 830519 NMS LIC30 34-00293-O2 PDR AcH mEar I
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- e Information Report l
Misadministration Therapy I
05te: February 17, 1983 Licensce flame:
Ohio State Universi ty Address:
Columbus, Ohio 43210 (Radiation Oncology Division, Radiology Department,410 V. Tenth AvenueL 1
Prescribed Dose:1 833 rads to Poi _nt'A' Administered Dose: 2,226 rads to Point
'A' 1
" Difference:
+ 21% (Please see comments on reverse)
Dates and Times' Involved: Brachytherapy Cesium-137 sources inserted at 4:40 pm_
1 Honday, February 14,1983 and removed after 30' hours of treatment at 10:40pm on Tuesd'ay, February 1[.1983
?!ame of Treating Physician:
Chung K. Yin, M.D.,
Staff Radiation Therapist flame of Referring Physician:
George Johnston, H.D.,.Gy_necologist Description of Event: The sources,2 anned to be 19.6 + 11.8 + 9.5 + 9. 5 mq 226 1
Ra_
equivalent 137Cs sources in the central tande,m and 11.8 mg Ra equivalent 137Cs sources in each ovolds, were loaded into the plastic inserts by the dosimertist prior to insertion in the af terloading applicator by the ' physician. Af ter the precalculated treatment time of 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />, the Radiation Therapy House Officer removed the sources and the appilcator and placed the source in the carrying cart in the radium room. On February 16th, the physicist replaced the sources in the_
safe, and as usual took a pre-and past rep' acem' nt inventory of sources in the l
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safe and the snurces replaced. Back 'n the' department, the inventory was being recorded in the ledger and a comparison of records showed that the ovoids were loaded with 17.4 mg 226Ra equivalent sources instead of the 11.8 mg equivalent.
The dosimetrist and therapist were notified of the incident immediately.
Effect of Administered Dose to Patient: Even tl.augh administered dose was highe_r i
than the planned dose, the total dose is well under the tolerence dose, so no irc.ediate and late complications are anticipated ( Chung K. Yin. H.D.)
i Action Taken to Prevent Reoccurance: Advised the dosimet rist of the requirement to inve)ory the sources in the safe by individually counting the sources in the safe aP the time of removal and replacement of sources. The at tached for_m wa_s_
prepared for use by the physics staf f, who always renove and replace sources in the safe. All_ phsics s taff handling the sources in and out of the safe _ars to use the form and take inventory of sources in the safe prior to af ter ren.ovi nd and replacing the sources by Individually counting and identifying the sources vSichareclearlycolorccged, inc lud ng the, inventory of the som ces recoved m.a.
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h Commen ts : A total dose of 6J00 rads to Point A' and 7,000 rads maximum dose to the vaginal mucosa, which ever comes first, was prescribed. 4,500 rads of the tota {
dose was delivered with external b'eams, and the balance was to be by brachyth'erapys The doses calculated prior to insertion of the sources were 1,833 rads to Point A and 2,500 rads to the surface of-the ovoids (which w'as taken as the maximum dose to the vaginal mucosa). The,mistoading of the ovoids with higher than planned activity sources resulted in the final doses of 2,226 rads and 3,417 rads respect-ively to Point A and the vaginal mucosa from brachytherapy alone, 21% and 37%
higher than the planned dose. However, the total treatment dose to Point A from
, external and internal treatment was 6,726 rads (3.5% higher) and maximum dose to
, _the vaginal mucosa was_M1] rads (a 13% hlqher) compared to the 6,500 rads and 7,000 rads planned at the start of the treatment.
A kn 4 e s.
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Frank Batley, M.D., Professo[ and Director, Date Radiation Oncology R50:_ l pg /
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