PNO-III-97-052, on 970602,physician Inserted Nylon Ribbon Containing 13 Ir-192 Seeds Totalling 28.53 Mci Into Patients Esophagus for Treatment of Cancer.Region III Will Perform Special Insp within Two Wks to Review Circumstances
| ML20141M005 | |
| Person / Time | |
|---|---|
| Site: | 03018133 |
| Issue date: | 06/03/1997 |
| From: | Phillips M, Thomas Young NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| References | |
| PNO-III-97-052, PNO-III-97-52, NUDOCS 9706040080 | |
| Download: ML20141M005 (1) | |
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June 3. 1997 D
l PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-III-97-052 This preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information is as initially i received without verification or evaluation, and is basically all that is '
i known by Region III staff (Lisle. Illinois) on this date.
Facility Licensee Emergency Classification l l MARPJETTE GENERAL HOSPITAL Notification of Unusual Event l Mecquette General Hospital Alert Marquette, Michigan Site Area Emergency l License No: 21-05432-04 General Emergency i
X Not Applicable
Subject:
BRACHYTHERAPY EVENT On June 2,1997, at 2:55 p.m., a physician inserted a nylon ribbon containing 13 iridium-192 seeds totalling 28.53 millicuries (1.0567 gigabecquerels) into a patient's esophagus for treatment of cancer.
Beginning at about 5:00 p.m. the patient encountered several coughing episodes and repositioned the esophageal tube that contained the ribbon.
At about 7:00 p.m. the nurse arrived with medication and noted that the esophageal tube was slightly displaced. The nurse subsequently contacted the physician and at about 7:30 p.m., the physician removed the ribbon i from the patient and terminated the treatment. ;
The licensee has concluded that during the actual treatment time of four l hours and 35 minutes. the absorbed dose actually delivered to the patient's treatment site was 224 centigray, and the absorbed dose delivered after the patient repositioned the esophageal tube was 280 centigray to unknown l xations within the esophagus. The physician's written directive prescribed 112 centigray per hour at 0.5 centimeter depth for 26 hours3.009259e-4 days <br />0.00722 hours <br />4.298942e-5 weeks <br />9.893e-6 months <br /> of treatment.
The licensee reported that no harmful effect to the patient is likely and will treat the patient again on June 5,1997. The licensee has notified the patient and referring physician.
Region III will perform a special inspection within two weeks to review the circumstances surrounding the event.
The State of Michigan and NRC Office of Nuclear Material Safety and Safeguards have been notified. The information in this preliminary I notification has been reviewed with licensee management.
The licensee notified the NRC Operations Center of this event at 8:41 ,
a.m. (CDT) on June 3. 1997. This information is current as of 3:30 p.m. j (CDT) June 3, 1997.
l
Contact:
MONTE PHILLIPS THOMAS YOUNG (630)829-9806 (630)829-9835 l u
g60 goo 970603 PNO-III-97-OS2 PDR 9 l
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