ML20151U898
| ML20151U898 | |
| Person / Time | |
|---|---|
| Issue date: | 04/29/1977 |
| From: | Roy G, Galen Smith, Thompson D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE) |
| To: | |
| References | |
| PNO-77-070, PNO-77-70, NUDOCS 9809110223 | |
| Download: ML20151U898 (2) | |
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PRELIMINARY NOTIFICATION 1
April 29, 1977 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE--PNO-77-70 This preliminary notification constitutes EARLY notice of an event of
. POSSIBLE safety or public interest significance. The information presented is as initially received without verification or evaluation and is basically all that is known by IE staff on this date.
Facility: Riverside Methodist Hospital Columbus, Ohio License No. 34-10055-03 Sub.4 v's EXCESSIVE TELETHERAPY DOSE DETERMINED TO BE CAUSE OF PATIENT'S DEATH Preliminary Notification Nos. PNO 76-75 and 76-110 described a series of events which resulted in a number of patients having been exposed to j
i therapeutic doses of radiation in excess of those prescribed from a teletherapy machine at Riverside Methodist Hospital in Columbus, Ohio.
The following item is considered as a continuance of that event and associated occurrences.
Region III (Chicago) received a report on April 25, 1977 from the NRC l
t medical consultant which identified the cause of death of Mrs. Agnes Carro,
.j a patient treated at Riverside Methodist Hospital during the period from 4
P October 5, 1975 to November 28, 1975, as " enteritis associated with fibrosis 1
ulceration and peritonitis due to excessive radiation." She was also a l
patient at the hospital from April 4, 1976 until her death on April 19, q
1976. The consultant's conclusion is that death was due to the adminis-j tration to the patient of approximately twenty-six percent more radiation i
than was prescribed.
q This patient was treated with the Riverside Methodist Hospital teletherapy L
unit during the period when the delivered dose to the patient exceeded the j
prescribed dose due to erroneous data being used to determine patient j
exposure time.
The Franklin County, Ohio, coroner's office has previously identified this case as one of two in which radiation exposure was a major contributor to death. The NRC medical consultant's evaluation of other deceased patients 4
involved is continuing.
Region III will provide a copy of the consultant's report to the Franklin 4
County, Ohio, coroner's office and Riverside Methodist Hospital, and the g/
3 State of Ohio Department of Health will be informed.
~A press release is under consideration.
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e CONTINUED i;
9909110223 770429 PDR I&E PNO-77-070 PDR l
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Paga 2 PNO-77-70 Continued April 29, 1977
Contact:
GHSmith, IE x 27353 GWRoy, IE x27261 DThompson, X27541 Distribution:
Transmitted H St M.' /b Chairman Rowden C. C. Kammerer, CA G. F. Murphy, JCAE
' t Commissioner Kennedy S. J. Chilk, SECY H. H. Whiteside, SCNR l
Commissioner Gilinsky H. R. Myers, HCEE Transmitted:
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L. V. Gossick, EDO E. G. Case, NRR C. V. Smith, NMSS S. H. Hanauer, EDO H. K. Shapar, ELD l
J. A. Harris, PA W. G. Mcdonald, MIPC Luge (mail);
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R. G. Ryan, OSP T. J.'dcTiernan, OIA Region
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PRELIMINARY NOTIFICATION l
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