PNO-III-97-044, on 970505,underdosage in Ir-192 Treatment Occurred,During Treatment W/High Dose Rate After Loader. Licensee Notified Patient Referring Physician,Who Plans to Notify Patient of Underdose Administered During Treatment
| ML20196G223 | |
| Person / Time | |
|---|---|
| Site: | 03001625 |
| Issue date: | 05/15/1997 |
| From: | Gattone R, Madera J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| References | |
| PNO-III-97-044, PNO-III-97-44, NUDOCS 9705150267 | |
| Download: ML20196G223 (1) | |
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,- May 15, 1997 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-III-97-044 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 III staff (Lisle, Illinois) on this date.
Facility Licensee Emergency Classification COMMUNITY HOSPITALS OF INDIANA. INC.
Notification of Unusual Event Community Hospitals Of Indiana. Inc Alert Indianapolis, Indiana Site Area Emergency License No: 13-06009-01 General Emergency X Not Applicable
Subject:
UNDERDOSAGE IN IRIDIUM-192 TREATMENT On May 12, 1997, the licensee reported that a medical event occurred on May 5,1997, involving an iridium-192 (Ir-192) brachytherapy implant in which the satient received less than the intended dosage during treatment with a hig1 dose rate (HDR) afterloader.
The physician's intended treatment for the patient was two fractions of 500 centigray (cGy) at 0.5 centimeter (cm) from the surface of the patient's ovoid for a total dose of 1000 cGy. The licensee's staff interpreted the treatment as 500 cGy at 0.5 cm from the surface of the Ir-192 source. Prior to the treatment, the physician reviewed and approved the treatment plan without realizing that the plan differed from his intended treatment. The resulting dose administered to the patient was 80 cGy, an 84% underdose from what was originally intended.
During preparation for the second HDR treatment on May 12, 1997. the
)hysician realized that the treatment on May 5, 1997, deviated from what le intended. The physician wrote the written directive for the second fraction prescribing 500 cGy at 0.75 cm from the surface of the patient's ovoid. The treatment was delivered properly. This treatment resulted in the patient receiving 750 cGy at 0.5 cm from the surface of the ovoid compensating for the underdose given during the administration of the first fraction. A total dose of 830 cGy was administered to the patient.
The licensee notified the patient's referring physician, who plans to notify tne patient of the underdose administered during the first treatment fraction.
NRC Region III (Chicago) is performing a special inspection in response to the event on May 15, 1997.
The State of Indiana and the NRC Office of Nuclear Materials Safety and Safeguards have been notified. The information in this preliminary notification has been reviewed with licensee management.
The licensee notified the NRC Operations Center of this event at 12:30 p.m. (CDT) on May 12, 1997. This information is current as of 11:00 a.m.
(CDT) on May 15, 1997.
Contact:
ROBERT GATTONE JOHN MADERA
\\b[f (630)829-9823 (630)829-9834
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9705150267 970515
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