PNO-III-98-022, on 980304,licensee Removed Ovoid Gynecological Applicator 12 H Earlier than Intended,Due to Transcription Error
| ML20199E510 | |
| Person / Time | |
|---|---|
| Site: | 03000842 |
| Issue date: | 03/06/1998 |
| From: | Jackie Jones, Wright G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| References | |
| PNO-III-98-022, PNO-III-98-22, NUDOCS 9901210002 | |
| Download: ML20199E510 (1) | |
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e i March 6,
1998 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-III-98-022 I
i 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 j
.known by Region III staff (Lisle, Illinois) on this date.
i Facility Licensee Emergency Classification i
UNIVERSITY OF MINNESOTA Notification of Unusual Event University Of Minnesota Alert Minneapolis, Minnesota Site Area Emergency License No: 22-00187-46 General Emergency X Not Applicable l
Subject:
BRACHYTHERAPY MISADMINISTRATION (UNDERDOSE)
On March 5, 1998, the licensee notified the NRC Operations Center and Region III (Chicago) of a brachytherapy misadministration. The
-misadministration, involving an underdose, was identified at t
approximately 10:30 a.m. local time on March 4, 1998.
on March 2, 1998, the licensee implanted a tandem and ovoid gynecological
-applicator using cesium-137 sealed sources, with a total activity of 168 millicuries, at 3:20 p.m., with an intended explant time of 9:20 p.m. on March 4, 1998, giving a 54 hour6.25e-4 days <br />0.015 hours <br />8.928571e-5 weeks <br />2.0547e-5 months <br /> treatment. The intended dose was 3240 l
rads. Due to a transcription error, the licensee, removed the applicator r
with the sources at 9:20 a.m. on March 4, 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> earlier than intended, l-resulting in a dose of 2604 rads, a 22 percent underdose.
i After being notified of the underdose, the referring physician and abthorized user have decided not to perform additional therapy to
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l compensate for the underdose. In addition they decided not to inform the l
patient of the underdose.
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The Office of Nuclear Materials Safety and Safeguards and the State of
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Minnesota.have been notified. Region III will conduct a followup inspection to review the misadministration within 10 working days.
The licensee notified the NRC Operations Center of this misadministration at about 11:12 EST on March 5, 1998. This information is current as of
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that time.
Contact:
JOHN JONES GEOFF WRIGHT (630)829-9032 (630)829-9602 i
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