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Category:PRELIMINARY NOTIFICATION OF EVENT OR OCCURRENCE (PNO
MONTHYEARPNO-III-99-004, on 990128,patient Apparently Removed Ribbon Containing Ir-192 Seeds During Radiation Therapy Procedure. Ribbon Had Been Inserted Through Patient Nose & Into Lungs for Treatment of Lung Cancer.Treating Physician Notified1999-02-0101 February 1999
PNO-III-99-004:on 990128,patient Apparently Removed Ribbon Containing Ir-192 Seeds During Radiation Therapy Procedure. Ribbon Had Been Inserted Through Patient Nose & Into Lungs for Treatment of Lung Cancer.Treating Physician Notified
PNO-III-98-026, on 970106,patient Prescribed 2,000 Rad Dose of Ir-192 & Received 108 Rads.Patient Removed Bronchial Catheter from Location.Nurse Recovered Catheter & Placed in Shielding Provided in Patient Room1998-03-19019 March 1998
PNO-III-98-026:on 970106,patient Prescribed 2,000 Rad Dose of Ir-192 & Received 108 Rads.Patient Removed Bronchial Catheter from Location.Nurse Recovered Catheter & Placed in Shielding Provided in Patient Room
PNO-III-98-024, on 970714,apparent Misadministration Occurred During Intrabronchial Brachytherapy Cancer treatment.Ir-192 Catheter Removed from Intended Site by Patient1998-03-10010 March 1998
PNO-III-98-024:on 970714,apparent Misadministration Occurred During Intrabronchial Brachytherapy Cancer treatment.Ir-192 Catheter Removed from Intended Site by Patient
PNO-III-96-014, on 960311,licensee Discovered Brachytherapy Source That Was Dislodged Due to Mishandling During Afterloading Procedure.Physician & RSO Immediately Inserted Source.Region III Will Conduct Special Insp on 9603201996-03-14014 March 1996
PNO-III-96-014:on 960311,licensee Discovered Brachytherapy Source That Was Dislodged Due to Mishandling During Afterloading Procedure.Physician & RSO Immediately Inserted Source.Region III Will Conduct Special Insp on 960320
1999-02-01
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Category:TEXT-INSPECTION & AUDIT & I&E CIRCULARS
MONTHYEARPNO-III-99-004, on 990128,patient Apparently Removed Ribbon Containing Ir-192 Seeds During Radiation Therapy Procedure. Ribbon Had Been Inserted Through Patient Nose & Into Lungs for Treatment of Lung Cancer.Treating Physician Notified1999-02-0101 February 1999
PNO-III-99-004:on 990128,patient Apparently Removed Ribbon Containing Ir-192 Seeds During Radiation Therapy Procedure. Ribbon Had Been Inserted Through Patient Nose & Into Lungs for Treatment of Lung Cancer.Treating Physician Notified
PNO-III-98-026, on 970106,patient Prescribed 2,000 Rad Dose of Ir-192 & Received 108 Rads.Patient Removed Bronchial Catheter from Location.Nurse Recovered Catheter & Placed in Shielding Provided in Patient Room1998-03-19019 March 1998
PNO-III-98-026:on 970106,patient Prescribed 2,000 Rad Dose of Ir-192 & Received 108 Rads.Patient Removed Bronchial Catheter from Location.Nurse Recovered Catheter & Placed in Shielding Provided in Patient Room
PNO-III-98-024, on 970714,apparent Misadministration Occurred During Intrabronchial Brachytherapy Cancer treatment.Ir-192 Catheter Removed from Intended Site by Patient1998-03-10010 March 1998
PNO-III-98-024:on 970714,apparent Misadministration Occurred During Intrabronchial Brachytherapy Cancer treatment.Ir-192 Catheter Removed from Intended Site by Patient
PNO-III-96-014, on 960311,licensee Discovered Brachytherapy Source That Was Dislodged Due to Mishandling During Afterloading Procedure.Physician & RSO Immediately Inserted Source.Region III Will Conduct Special Insp on 9603201996-03-14014 March 1996
PNO-III-96-014:on 960311,licensee Discovered Brachytherapy Source That Was Dislodged Due to Mishandling During Afterloading Procedure.Physician & RSO Immediately Inserted Source.Region III Will Conduct Special Insp on 960320
1999-02-01
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March 10, 1998 PRELIMINARY NOTI.'ICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-III-98-024 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 DETROIT MACOMB HOSPITAL CORPORATION Notification of Unusual Event Detroit Macomb Hospital Corporation Alert Warren, Michigan Site Area Emergency License No: 21-01190-05 General Emergency X Not Applicable
Subject:
POSSIBLE MI3 ADMINISTRATION INVOLVING AN UNDERDOSE OF IRIDIUM-192 On March 5, 1998, during a routine inspection at Detroit Macomb Hospital Corporation, Warren, Michigan, an NRC inspector identified a potential medical misadministration that had occurred on July 14, 1997, involving an underdose and a dose to a wrong treatment site.
i The apparent misadministration occurred during an intrabronchial [
brachytherapy cancer treatment to a patient. The prescribed dose for this i treatment was 1502 rads (15.02 gray), and the dose received was 614.25 ;
rads (6.14 Gray). During treatment, a catheter containing 35.6 >
mil 11 curies (1.32 gigabecquerel) iridium-192 seeds was inadvertently removed from the intended treatment site by the patient. Apparently, the patient pulled the catheter out when adjusting eye glasses or oxygen tubing, possibly during associated coughing. This resulted in a calculated dose of 103 rads (1.03 gray) to the skin of an unintended site.
The patient was notified immediately following discovery by the authorized user physician. The referring physician was notified verbally and in writing by the' authorized user physician. The licensee did not recognize the event to be a misadministration, however, the event was reported to the Radiation Safety Committee on July 21, 1997. The attending physician reported no adverse health effects to the patient as a result of this event.
The State of Michigan 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 reported the event to the NRC Operations Center at 2:10 p.m.
(EST) on March 6, 1998. This information is current as cf 10:00 a.m. on March 10, 1998.
Contact:
MARK W. MITCHELL GEOFFREY C. WRIGHT (630)829-9855 (630)829-9602 9901210023 980310 "
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