PNO-II-97-062, on 971211,licensee Reported That Between Apr 1995 & Jul 1996 Nine Misadministrations Involving Sr-90 Eye Applicator Occurred,As Result of Apparent Incorrect Decay Calculation of Source.Commonwealth of Pr Will Be Notified
| ML20203A847 | |
| Person / Time | |
|---|---|
| Site: | 03017134 |
| Issue date: | 12/11/1997 |
| From: | Hosey C NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | |
| References | |
| PNO-II-97-062, PNO-II-97-62, NUDOCS 9712120237 | |
| Download: ML20203A847 (1) | |
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Y-December 11, 1997 ERJWIMIl&RY.HOh'IflCATION__OF EVENT OR UNUSUAL OCCURRERGE PNO-II-97-062 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 Region II staff in Atlanta, Georgia on this date.
EMill1Y IdIL9.GR_o e EmetI_qg.ILqy__QJag.gif i c a t i on Joue N. De Leon, M.D.
Notification of Unusual Event Rio Piedras, Puerto Rico Alert Dockets: 03017134 License No: 52-19206-01 Site Area Emergency General Emergency X Not Applicable
Subject:
MEDICIAL MISADMINISTRATION INVOLVING STRONTIUM 90 EYE APPL 1CATOR On December 11, 1997, the licensee reported that between April 1995 and July 1996 nine misadministrations involving a strontium-90 cye applicator occurred as a result of an apperent incorrect decay calculation af the cource. The authorir.ed user reported that he intended to deliver 2000 rada. Based upon the incorrect calculation, the dose delivered to the patients was approximately 100 percent greater than the dose intended.
The authorized user stated that the treatment window was 1,000 to 6,000 rada. The strontium-90 eye applicator was not used after July, 1996.
The error in the treatment time was identified by a Region II inspector du::ing a routine inspection.
The commonwealth of Puerto Rico will be notified by Region II.
This information is current as of 4:00 p.m.
on December 11, 1997.
Contact:
C.
HOSEY (404)S62-4701 9712120237 971211 PDR L&E PNO-II-97-062 PDR 1
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