PNO-III-97-088, on 971029,patient Received Series of Co-60 Teletherapy Treatments with Total Dose of 31% Greater than Prescribed Dose.Licensee Intends to Modify Treatment Plan to Adjust Dose
| ML20206R542 | |
| Person / Time | |
|---|---|
| Site: | 03014637 |
| Issue date: | 10/31/1997 |
| From: | Madera J, Parker G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| References | |
| PNO-III-97-088, PNO-III-97-88, NUDOCS 9901200001 | |
| Download: ML20206R542 (1) | |
-- _ - - - . . ~ . . - _ - - - - - - - - _ . _ - - ~ . - = - - - ~ . . - - .
e
- e e
October 31, 1997 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-III-97-088 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 '
GRANT RIVERSIDE METHODIST HOSPITAL Notification of Unusual Event Grant Riverside Methodist Hospital Alert Columbus, Ohio Site Area Emergency ;
License No: 34-03424-03 General Emergency X Not Applicable
Subject:
THERAPEUTIC MISADMINISTRATION On October 30, 1997, the licensee reported that a patient had received a i series of cobalt-60 teletherapy treatments with a total dose of about 31 ,
percent greater than that prescribed 2or the teletherapy series. ,
The treatment plan called for a series of 13 cobalt-60 teletherapy -
treatments of 180 rads (180 centigray) each followed by a series of 13 treatments of 180 rads (180 centigray) using a linear accelerator. (The teletherapy treatments are under the hospital's NRC license, and linear accelerator treatments are under state regulation.)
The licensee administered 17 treatments using the cobalt-60 teletherapy '
device instead of the intended 13. This resulted in a total teletherapy dose of 3,060 rads (3,060 centigray) instead of the intended 2,340 rads (2,340 centigray). This dose is 31 percent greater than that intended.
The treatment series began on October 6, and the licensee discovered the
( misadministration following the 17th treatment on October 29.
The licensee intends to modify the treatment plan to reduce the number of linerar accelerator treatments. This modification will result in a combined dose for the teletherapy and linear accelerator treatments which
. approximates the total combined dose originally intended.
I l Region III (Chicago) has begun a special inspection to review the l circumstances surrounding the misadministration. An NRC medical consultant
, will be retained, if appropriate.
The State of Ohio will be notified. The information in this preliminary notification has been reviewed with the licensee.
^
The licensee notified the NRC Operations Center of this misadministration at 4:29 p.m. EST. on October 30, 1997. This information is current as of 10 a.m. EST on October 31, 1997.
Contact:
GEORGE PARKER JOHN MADERA I (630)829-9869 (630)829-9834 4 - .rn 4 i 9901200001 971031 (
PDR IbE
- N 1 PNO-III-97-088 PDR L O l
. -.