PNO-II-98-011, on 980304,therapeutic Misadminstration to Wrong Traetment Site Occurred.Female Patient Being Treated W High Dose Rate Afterloading Device Containing 3.22 Curies of Ir-192.State Will Complete Evaluation Upon Ack of Full Rept
| ML20217P342 | |
| Person / Time | |
|---|---|
| Issue date: | 03/06/1998 |
| From: | Woodruff R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | |
| References | |
| PNO-II-98-011, PNO-II-98-11, NUDOCS 9803100225 | |
| Download: ML20217P342 (1) | |
i l
I
,.. March 6,
1998 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-II-98-011 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.
E&nility Licensee Emercency Classification Athens Regional Medical Center Notification of Unusual Event (Jbt Agreement State Licensee)
Alert Athens, Georgia 30613 Site Area Emergency L License No: GA 4-1 General Emergency i
X Not Applicable l
l
Subject:
THERAPEUTIC MISADMINISTRATION TO WRONG TREATMSNT SITE l The State of Georgia Radioactive Materials Program notified NRC of a minadministration that occurred at the licensee's facility on March 4, 1998.
The female patient was being treated with a high dose rate (HDR) il afterloading device containing 3.55 curies of iridium-192. On the day of the event, the patient had a catheter in the urethra for the HDR treatment, and a second catheter in the bladder for an unrelated medical procedure. The physician reportedly reviewed the films during the trial run for the treatment and determined that the HDR cacheter was properly placed.
The treatment was delivered.
While removing the source, the l
licensee discovered that the HDR had been placed in the bladder catheter, L which delivered the dose to the bladder, the wrong treatment site.
This l treatment was one of multiple treatments intended to deliver a total dose of 3000 rads.
The patient was retrehted at the correct site the same day.
The licensee reportedly informed the physician and the patient of the
,l misadministration, and the licensee understands that a written report is i to be provided to the patient and to the State with dose calculations by March 18, 1998.
The State will complete their evaluation upon receipt of the full report from the licensee.
This information is current as of 11:00 a.m.,
March 6, 1998.
I i
Contact:
R. Woodruff i
(404)562-4704 i
9 gwa y.p/t-s-l f
9803100225 980306 g,
P DR I&E PNO-II-98-011 PDR.
wo o
m