PNO-IV-98-028, on 980624,therapeutic Misadministration Occurred at Univ of CA San Diego Medical Ctr,San Diego,Ca. Event Involved One of Several Fractional Brachytherapy Treatments Planned for Treatments of Cervical Cancer
| ML20249C278 | |
| Person / Time | |
|---|---|
| Issue date: | 06/25/1998 |
| From: | Horner J, Linda Howell NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| References | |
| PNO-IV-98-028, PNO-IV-98-28, NUDOCS 9806260298 | |
| Download: ML20249C278 (1) | |
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RR June 25,1998 PRELikilNARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-IV-98-028 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 IV staff in Arlington, Texas on this date.
Facility Licensee Emeraency Classification University Of California San Diego Med Ctr Notification of Unusual Event U Of Califomia San Diego Med Ctr Alert San Diego, California Site Area Emergency License No: CA 1339-37 General Emergency X Not Applicable
Subject:
THERAPEUTIC MISADMINISTRATION A therapeutic misadministration occurred at the University of Califomia San Diego Medical Center, San Diego, California, on June 24,1998. The event was reported to Don Bunn of the State of Califomia, and he subsequently reported the event to Region IV at 4:04 p.m., June 24,1998.
The event involved one of several fractional brachytherapy treatments planned for treatment of a patient's cervical cancer. Cesium-137 seeds implanted for one fractional treatment were
' left in the patient 1 day longer than called for in the brachytherapy treatment plan. The intended dose was 2000 centigray; however, based on the licensee's preliminary calculations, the actual dose may be as high as 3400 centigray. Although the actual dose exceeded the prescribed dose for this fractional treatment, the authorized user physician has indicated that including the 3400 centigray dose, the dose delivered to the treatment area is within the overall intended dose. The Medical Center is continuing to investigate this misadministration and will submit a complete report to the state within 30 days, at which time the state will forward it to Region IV.
Region IV received notification of this event by e-mail from the state of Califomia. This information has been reviewed with the state and is current as of 11:00 a.m. (CDT), June 25, 1998.
Region IV has informed NMSS.
Contact:
Linda L. Howell (817)860-8213 Jack Homer (925)975-0224 K I K
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PDR ItaE PNO-IV-98-023 PDR k
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