PNO-III-86-135, on 861006-08,patient Mistakenly Exposed to 2,000 Rads Instead of Prescribed 1,200 Rads During Co-60 Treatment for Blood Disease.Caused by Personnel Error. Misadministration Will Be Reviewed by NRC
| ML20214F903 | |
| Person / Time | |
|---|---|
| Site: | 03000394 |
| Issue date: | 11/17/1986 |
| From: | Axelson W, Wiedeman D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| References | |
| FRN-52FR36942, RULE-PR-35 AC65-1-077, AC65-1-77, AC65-77, PNO-III-86-135, NUDOCS 8611250476 | |
| Download: ML20214F903 (1) | |
PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE--PNO-III-86-135 Data Novemb2r 17, 986 This preliminary notification constitutes EARLY notice of events of POSSIBLE safety cr public interest significance. The information is as initially received without v;rification or evaluation, and is basically all that is known by the Region III staff on this date.
Facility: Cleveland Clinic Foundation Licensee Emergency Classification:
9500 Euclid Avenue Notification of an Unusual Event Cleveland, OH Alert Site Area Emergency License No. 34-00466-02 General Emergency X Not Applicable 4
Subj ct: THEPAPEUTIC MISADMINISTRATION The licensee reported that an elderly, terminally ill patient was exposed to 2000 rads of radiation rather than the prescribed 1200 rads while undergoing cobalt-60 teletherapy treatment for a blood disease.
The treatment, which covered the patient's upper torso, began October 6, 1986, and ended October 8, 1986. The error was discovered on November 11, 1986, but was not reported to the NRC until November 17, 1986. The delay was apparently due to the licensee's failure to realize that a misadministration of this type requires imediate notification.
Th3 excess exposure resulted from an error in the treatment calculations, and was discovered when the patient was admitted to the clinic with skin complications.
An NRC medical consultant has been notified and will promptly review the misadministration.
The hospital is required to submit a written report on the incident, including a description of correction actions, within 15 days of the initial report. Region III (Chicago) has scheduled an onsite inspection to review the incident. ,
Tha State of Ohio will be notified.
This infonnation is current as of 12:30 p.m. (CST), November 17, 1986.
h CONTACT: W. # G. Weideman FTS 388-5616 W. L. Axelson FTS 388-5612 46b 0 \
DISTRIBUTION:
H. St. ED0 NRR E/W Willste Mail: ADM:DMB Chairman Zech PA IE NMSS D0T:Trans only Com. Roberts ELD OIA RES Comm. Asselstine AE0D Com. Bernthal Com. Carr SP /,'.19 Regional Offices ACRS SECY INP0 NSAC ;
CA RIII Resident Office PDR Licensee: (Corp. Office - Reacter Lic. Only) gg y $ 6 861118 Region III PNO-III-86-135 PDR Rev. November 1985
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