PNO-I-87-074A, from 1981-1987,22 Teletherapy Misadministrations Occurred,Including Under Treatments & Over Treatments.Caused by Errors from One Physicist.All Treatment Records Dating from 1981 Reviewed
| ML20237J278 | |
| Person / Time | |
|---|---|
| Issue date: | 08/20/1987 |
| From: | Mcgrath J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| References | |
| FRN-52FR36942, RULE-PR-35 AC65-1-008, AC65-1-8, PNO-I-87-074A, PNO-I-87-74A, NUDOCS 8708260097 | |
| Download: ML20237J278 (4) | |
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DCS No:
99999870806 Date:
08/20/87 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE--PNO-I-87-74A This preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information is as initially received without verification or evaluation, and is basically all that is known by the Region I staff on this date.
Facility:
Licensee Emergency Classification:
Northern Westchester Medical Center Notification of Unusual Event Alert Site Area Emergency General Emergency X
Not Applicable
Subject:
TELETHERAPY MISADMINISTRATION This is to provide an update of PNO-I-87-74 in which Region I reported receiving a call' from the New York State Department of Health regarding a dosimetry problem at Northern Mestchester Medical Center (NWMC).
It is now known that 22 teletherapy misadministra-tion occurred at NWMC during the years 1981-1987.
We do not yet have complete details on the 22 cases, but we do know that there were a number of under-treatments as well as over treatments. The five cases with the highest delivered doses exceeding the intended dose are as follows:
Intended Dose (Rads)
Actual Delivered Dose (Rads)
Case A 3600 4800 Case B 3500 6600 Case C 4985 8500 Case D 1250 2800 Case E 4800 6600 The misadministration were apparently the result of errors made by one particular physicist employed by Radiological Physics Associate (RPA) of Elmsford, NY.
The errors were made in the calculation of machine on-time from information provided from a computer generated treatment plan.
There was apparently no consistency in the type of errors made. For example in some cases the physicist simply misread numbers.
In other cases, he misinterpreted the data from the computer treatment plan, e.g. the computer plan used source-axis treatment distances which the physicist read as source-skin distance.
The errors in the 22 cases at NWMC were independently verified by 5 medical physicists (2 associates at RPA, 2 from New York University, and one
. independent consultant). All treatment records dating back to 1981 were reviewed.
The State requested RPA to provide the names of other institutions where the physicist had performed similar consulting services and received the names of two hospitals, Columbia Memorial in Hudson, NY and Samaritan Hospital in Troy, NY.
The hospitals were centacted and initiated a review of their treatment records.
Columbia Memorial has discovered 7 cases where errors were made, one over-treatment (intended dose-5000 rads, actual dose delivered-6300 rads) and 6 under treatments (some of which may not qualify as misadministration).
Samaritan Hospital has not yet completed their evaluation.
l 8700260097 870020 PDR 18e P NO-] --87 -074 A PIlR
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