PNO-III-98-008, on 980115,licensee Treated Patient to Prevent Restenosis of Coronary Artery for Addl 60 to 90 Seconds Due to Difficulty Returning Pellets to Storage Device.Cause Under Investigation
| ML20206R701 | |
| Person / Time | |
|---|---|
| Site: | 03002271 |
| Issue date: | 01/20/1998 |
| From: | Jackie Jones, Thomas Young NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| References | |
| PNO-III-98-008, PNO-III-98-8, NUDOCS 9901200093 | |
| Download: ML20206R701 (1) | |
.
g.
e
. January 20, 1998 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-III-98-008 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 WASHINGTON UNIVERSITY AND Notification of Unusual Event MEDICAL CENTER Washington University And Alert Medical St. Louis, Missouri Site Area Emergency License No: 24-00167-11 General Emergency X
Not Applicable
Subject:
BRACHYTHERAPY MISADMINISTRATION (PRONG TREATMENT SITE)
On January 15, 1998, the licensee treated a patient to prevent restenosis of a coronary artery. The licensee used 12 pellets of strontium-90 (35 millicuries, total) [1.3 gigabecquerels, total) to deliver a radiation dose of 1,400 centigray to the outer wall of the coronary artery at the treatment site. The delivery system consisted of a syringe used to apply hydraulic pressure to saline solution within the double catheter that was used to transport the pellets to the treatment site.
The normal transit time of the pellets from the storage device to the treatment site was three to five seconds. After the three minute treatment time, the physician encountered difficulty in returning the pellets to the storage device so the physician removed the entire catheter containing the pellets from the patient and placed the catheter into a shielded container.
The licensee estimated that the pellets were in the patient about an additional 60 to 90 seconds. The licensee estimated that during the normal transit time, the outer wall of the artery received a radiation dose of about 1 centigray. The licensee estimated that during the additional minute to remove the catheter from the patient, the outer wall of the artery received about 300 centigray. The licensee is still in the process of investigating the cause of this event.
The licensee will notify the treating physician and referring physician and patient.
NRC Region III (Chicago) contacted the NRC Office of Nuclear Materials Safety and Safeguards and the State of Missouri. A medical consultant has agreed to review this matter. An NRC inspector will complete a special inspection of the event within a week. The information in this preliminary notification was reviewed with licensee management.
NRC Operations Center was notified of this event at 1:30 p.m. ET on January 16, 1998.
This information was current as of 9:00 a.m.
(CST) on January 20, 1998.
Contact:
THOMAS YOUNG JOHN JONES (630)829-9835 (630)829-9832 9901200093 980120
?fI
'~
PDR I&E PNO-III-98-008 PDR O 9 I
.