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
| ML20199E562 | |
| Person / Time | |
|---|---|
| Site: | 03002005 |
| Issue date: | 03/19/1998 |
| From: | Matthew Mitchell, Wright G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| References | |
| PNO-III-98-026, PNO-III-98-26, NUDOCS 9901210019 | |
| Download: ML20199E562 (1) | |
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I March 19, 1998 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-III-98-026 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.
l Facility Licensee Emergency Classification l i
DETROIT MACOMB HOSPITAL CORPORATION Notification of Unusual Event l Detroit Macomb Hospital Corporation Alert
- Warren, Michigan Site Area Emergency
! License No: 21-01190-05 General Emergency i X Not Applicable 1
Subject:
POSSIBLE MEDICAL MISADMINISTRATION INVOLVING AN UNDERDOSE OF l IRIDIUM-192 i l On March 17, 1998, during continuing review of events identified during routine onsite inspection at Detroit Macomb Hospital Corporation, Warren,
- Michigan, the NRC identified a potential medical misadministration l involving an underdose that had occurred on January 6, 1997.
The apparent misadministration occurred during an intrabronchial brachytherapy cancer treatment to a patient. The prescribed dose for this treatment was 2000 rads (20.0 gray), and the dose received was 108 rads (1.08 gray). No other site received an unintended dose. The 20 iridium-192 (Ir-192) seeds totaling 31 millicuries (1.15 gigabecquerel) i in the catheter were intended to be in place for 26 hours3.009259e-4 days <br />0.00722 hours <br />4.298942e-5 weeks <br />9.893e-6 months <br />. Approximately
! 4:00 p.m. or 1.41 hours4.74537e-4 days <br />0.0114 hours <br />6.779101e-5 weeks <br />1.56005e-5 months <br /> after implantation, the patient pulled the i bronchial catheter, containing the Ir-192 seeds, from their location. A nurse, who was in the room attending the patient, recovered the catheter immediately and placed it in the shielding provided in the patient room for such an event. The RSO was called immediately and the RSO and authorized user arrived at the patient's room within approximately 5 minutes.
The patient was notified immediately following discovery by the authorized user physician. The referring physician was notified by the authorized user physician. The licensee did not recognize the event to be a misadministration but an event of patient intervention of a planned treatment. The attending physician reported no adverse health effects to t the patient as a result of this event and the treatment was terminated.
l There was no attempt to retreat the patient. 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 was instructed by NRC staff to reported the event to the NRC Operations Center on March 18, 1998. This information is current as of 3:00 p.m. on March 18, 1998.
i
Contact:
MARK W. MITCHELL GEOFFREY C. WRIGHT (630)829-98S5 (630)829-9602 9901210019 980319 PDR I&E PNO-III-90-026 PDR_
r i c>p e