PNO-IV-97-046, on 970826,licensee Teletherapy Physicist Reported That Misadministration Occurred.Authorized User Performed Second Treatment on Patient Later in Day & Successfully Completed Delivery of Intended Dose
| ML20210Q279 | |
| Person / Time | |
|---|---|
| Site: | 03022280 |
| Issue date: | 08/28/1997 |
| From: | Jonathan Montgomery, Spitzberg B NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| References | |
| PNO-IV-97-046, PNO-IV-97-46, NUDOCS 9708290071 | |
| Download: ML20210Q279 (1) | |
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1 August 28,1997 NELildlNARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-IV 97
- This preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information is as initially received without verlilcation or evaluation, and is basically all that is known by Region IV staff in Arlington, Texas on this date.
Easildy Licensee Emeroency Classification West Los Ange es Medical Center Notification of Unusual Event West Los Angeles Medical Center Alert Los Angeles, California Site Area Emergency Dockets: 03022280 License No: 04 00181 12 General Emergency X Not Applicable
Subject:
REPORT OF TELETHERAPY M!SADMINISTRATION The licensee's teletherapy physicist reported that a mindministration occurred on August 26,1997, involving irraiation of the wrong site duilng a treatment performed with a cobalt 60 teletherapy unit. While setting up treatment parameters, the licensee's authorized user physician apparently misread body treatment markings (referred to as
" tatoos") causing a 10 centimeter teletherapy beam misalignment. The licensee estimates the misalignment resulted in a delivered dose of approximately 300 centigray (300 rads) to the wrong site adjacent to the spine of an elderly male patient. Due to the misalignment, an equal area of the patlent's tumor received 300 centigray less than intended. The authorized user performed a second treatment on the patient later in the day (August 26th) and successfully completed deliverv of the intended dose.
The state of California has been informed, i
Region IV will dispatch an inspector to the licensee's facility to review this event.
Region IV received notification of this occurrence by telephone from the licensee's teletherl.py physicist at 2 o.m., August 27,1997. Hegion IV has informed NMSS.
This information has beeri discussed with the licensee and is current as of 2 p.m.,
August 27,1997.
Contact:
Blair Spitzberg Jim Montgomery (817)860-8191 (510)975 0249 I
9708290071 970828 NO 7-046 PDR;
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