PNO-IV-99-028, on 990624,NRC Notified by Alaska Regional Hosp Radiation RSO That Brachytherapy Misadministrations Had Occurred.Licensee Plans to Obtain Correct Insert for Applicator.Region IV Will Be Dispatching Inspector
| ML20196F892 | |
| Person / Time | |
|---|---|
| Site: | 03014720 |
| Issue date: | 06/25/1999 |
| From: | Collins E, Skov D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| References | |
| PNO-IV-99-028, PNO-IV-99-28, NUDOCS 9906290338 | |
| Download: ML20196F892 (1) | |
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June 25,1999 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-IV-99-028 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.
Epcility L.icensee Emeroency Classification Columbia Notification of Unusual Event j
i HCA Healthcare Corp.
Alert j
Alaska Regional Hospital Site Area Emergency j
2801 De Barr Road General Emergency Anchomge, Alaska 99514-3189 X Not Applicable Dockets: 030-14720 License No: 50-18244-01
Subject:
MEDICAL MISADMINISTRATIONS On June 24,1999, the NRC was notified by Alaska Regional Hospital's (ARH) Radiation Safety Officer (RSO) that four brachytherapy misadministrations had occurred. On June
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24,1999, a radiologist reviewed a radiograph of the brachytherapy applicator placement.
He determined that the sources used during the treatment were out of position by about 1 cm. A subsequent review by the licensee found that three other brachytherapy procedures had been performed within the last 2 months using the same applicator.
The licensee attributed the misadministrations to the use of an incorrect replacement insert which was used in conjunction with a "Duiclos mini ovoid" applicator. ARH ordered the replacement insert from Radiation Products Design. At this time, the licensee does not know how the incorrect replacement part was obtained. The licensee plans to obtain the correct insert for the applicator.
The replacement part was approximately 1 cm. shorter in length than the original part.
This shorter length resulted in radiation doses to the planned treatment sites less than the prescribeo doses as follows: three patients were prescribed 3000 cGy (rads) and one patient was prescribed 2500 cGy (rads), and received doses of 1874 cGy,2035 cGy, i
2004 cGy and 1822 cGy respectively, investigation of the root cause is ongoing and ARH personnel are ana!yzing known data to determine the medical significance of the misadministrations.
Region IV will be dispatching an inspector the week of June 28,1999.
The State of Alaska has been notified.
RIV received notification of this occurrence by the NRC Operations Center at 7:27 p.m.
(ET) on June 24,1999. Region IV has informed NMSS.
1 This information has been discussed with the licensee and is current as of 2 p.m. (CT)
\\(b June 25,1999.
Contact:
David S. SkovElmo E. Collins (925)372-7768(817)860-8291 9906290338 990625 i
PDR ItsE PNO-IV-99-028, PDR,
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