PNO-IV-98-058, on 981125,medical Misadministration Occurred. Event Involved Nucletron Afterloader with Ir-192 Source. Brachytherapy Dosimetrist Entered Wrong Starting Position, 1500 Mm Rather than Intended 1450 Mm.Nmss Has Been Informed
| ML20196B819 | |
| Person / Time | |
|---|---|
| Site: | 03014522 |
| Issue date: | 11/30/1998 |
| From: | Brown R, Collins E NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| References | |
| PNO-IV-98-058, PNO-IV-98-58, NUDOCS 9812010192 | |
| Download: ML20196B819 (1) | |
p .9 November 30,1998 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-!V-98-058 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 Queen's Medical Center Notification of Unusual Event Queen's Medical Center Alert Honolulu, Hawaii Site Area Emergency Dockets: 03014522 General Emergency License No: 53-16533-02 X Not Applicable
Subject:
MEDICAL MISADMINISTRATION The Operations Center received a call on November 26,1998, from the Radiation Safety Officer (RSO) for Queen's Medical Center, Honolulu, Hawaii, reporting a medical misadministration which had occurred on November 25,1998. The event involved a Nucletron afterloader with an Iridium (tr-192) source. The brachytherapy dosimetrist entered the wrong starting position,1500 mm rather than the intended 1450 mm. The pre-treatment data were checked by the brachytherapy physicist and the authorized user. Neither of the three individuals detected the entry error. The error was discovered later the same day while reviewing the case with a second brachytherapy physicist. The RSO was notified at home on November 25,1998, at 4:30 p.m. (HST). The patient had been treated and discharged.
On November 26,1998, the RSO reviewed the case and determined the error constituted a medical misadministration. Since this was a holiday, the authorized user, brachytherapy dosimetrist, and brachytherapy physicist were not available. The referring physician and patient were notified on November 25,1998. The patient received 500 cGy (500 rads) to an unintended section of the right bronchus. It is unlikely that this dose will be harmful to the tissues.
NMSS has been informed of this occurrence.
The state of Hawaii has been informed.
Region IV will conduct a followup inspection. This information has been discussed with the licensee and is current as of 1 p.m. on November 27,1998.
Contact:
R. A. Brown (817)860-8130 E. E. Collins 8 (817)'60-8291 a
9812010192 981130 I PDR I&E PNO-IV-98-058 PDR {l I.' ) l } 1 b