PNO-II-98-012, on 980305,notified NRC of Two Medical Misadministrations Occurred in 1994.First Misadministration Involved Use of Sr-90 Eye Applicator for Treatment of Pterygium on 940823 & Second Occurred on 940927
| ML20217P421 | |
| Person / Time | |
|---|---|
| Site: | 03034060 |
| Issue date: | 03/06/1998 |
| From: | John Pelchat NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | |
| References | |
| PNO-II-98-012, PNO-II-98-12, NUDOCS 9803100244 | |
| Download: ML20217P421 (1) | |
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g March 6,
1998 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-II-98-012 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.
Facility Licensee Emercency Classification Jose Colon Vaquer, M.D.
Notification of Unusual Event Manati, Puerto Rico Alert Dockets: 03034060 License No: 52-25113-02 Site Area Emergency General Emergency X Not Applicable
Subject:
STRONTIUM 90 EYE ALPPLICATOR MISADMINISTRATION On March 5, 1998, the license notified the NRC of two medical misadministrations that had occurred in 1994. Both misadministrations were initially identified by NRC inspectors during a routine inspection of the licensee's activities on March 5.
The misadministrations involved the use of a strontium 90 (Sr-90) eye applicator for the treatment of pterygium. The first misadministration occurred on August 23, 1994, when a patient received a dose of 1,500 rads over a period of thirty seconds. The prescribed dose was 1,000 rads over a period of 20 seconds. The second misadministration occurred on September 27, 1994, when a patient received a dose of 1,000 rads over a period of 21 seconds. The prescribed dose was 1,500 rads over a period of thirty seconds. The licensee stated that both patients had been notified and that the patients were not expected to experience any adverse health effects a s a result of the misadministrations, j
NRC Region II staff will review the licensee's written report and evaluate the need for an NRC Medical Consultant.
The Commonwealth of Puerto Rico has been notified.
This information current as of 11:00 a.m.,
March 6, 1998.
Contact:
J.
M.
Pelchat 4
(404)S62-4729 9003100244 980306 P DR I&E PNO-II-98-012 PDR l
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