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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\n-(. QWy-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 !
i events which resulted in a number of patients having been exposed to j 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, 4 .j a patient treated at Riverside Methodist Hospital during the period from . .
P October 5, 1975 to November 28, 1975, as " enteritis associated with fibrosis 1
l ulceration and peritonitis due to excessive radiation." She was also a 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 j prescribed dose due to erroneous data being used to determine patient
- 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 4
death. The NRC medical consultant's evaluation of other deceased patients involved is continuing.
4 Region III will provide a copy of the consultant's report to the Franklin 3
County, Ohio, coroner's office and Riverside Methodist Hospital, and the g/
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
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Commissioner Kennedy S. J. Chilk, SECY H. H. Whiteside, SCNR l Commissioner Gilinsky H. R. Myers, HCEE Transmitted: MNBBM'.0$; P Bldg 2 I/7 ; SS Bldg J..'e7 0 ; ,
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); E. Vol IE j R. G. Ryan, OSP T. J.'dcTiernan, OIA Region , M,NP, a
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l PRELIMINARY NOTIFICATION l
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