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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 45579 | 15 December 2009 05:00:00 | Agreement State | Agreement State Report - Possible Misadministration of Radioactive Medical Treatment | The following report was received via facsimile: (Tennessee Division of Radiological Health) TN DRH was notified on 12/15/09, by the medical physicist at Cookeville Regional Medical Center, of a possible therapeutic misadministration that occurred the morning of 12/15. A patient was being treated with three sealed sources of cesium-137 (total activity of 70 mg Ra-equivalent) contained in a vaginal applicator. The patient was elderly and heavily sedated. The applicator was inserted and after twenty minutes of treatment, the nurse came into the room to check on the patient and noticed the applicator outside the treatment area. The applicator was removed and placed in a lead pig. The patient may have received a maximum dose of 76 Rem to the thigh area. A written report will be submitted by the licensee. Tennessee Report Number: TN-09-155 A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. |