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List of results

• PNO-III-90-001, on 891229,licensee Reported Loss of 2 Mci Cs-137 Brachytherapy Needle Discovered During Routine Sealed Source Inventory on 891228 & Believed Placed Inadvertently in Trash on 891023.Notice Posted Notifying Personnel  + (03002283)
• PNO-III-93-009, on 930217,patient Inadvertently Removed Brachytherapy Catheter Before Radiation Treatment Was Completed.Caused by Patient Intervention.Catheter Was Retrieved & Physician Thinks Dosage Was Sufficient  + (03002283)
• ML18193A843  + (03002286)
• ML20032E304  + (02700048)
• ML20032E311  + (02700048)
• ML20032E317  + (02700048)
• ML18221A119  + (03002305)
• ML18197A355  + (03002308)
• PNO-III-98-054, on 981006,medical Event Involving Dose to Fetuses Occurred.Licensee Received Verbal Confirmation from Patient That She Was Not Pregnant,Prior to Administering Dose.Licensee Notified Referring Physician of Event  + (03002310)
• PNO-I-94-001A, on 940104,licensee Informed Region I That Seal Source Containing Approx 258 Uci of Cs-137 Was Missing from Storage Facility.Search Performed & Cs-137 Found Inside Shielded Container.No Personnel Exposed to Radiation  + (03002533)
• PNO-I-80-099, on 800710,SG Bluestein Reported That Package Containing 4.4 Mci I-131 Had Been Stolen from Private Automobile  + (03002533)
• PNO-IV-88-061, on 880730,excessive Radiation Levels Found on Incoming Mo-99/Tc-99m Generator.Efforts to Survey Delivery Personnel & Vehicle & Determine Cause of Excessive Radiation Underway  + (03002583)
• PNO-IV-88-061A, on 880802,Cintichem Representative Performed Radiation Surveys on Mo-99/Tc-99m Generator Received W/ Excessive Radiation Levels.No Damage or Leakage to Generator Found.Results May Be Invalid  + (03002583)
• PNO-I-97-029, on 970509,apparent Misadministration Involving under-dosing Patient w/I-131 Occurred.Two Technologists Involved in Measurement of Dose.Patient Properly Identified & Dose Administered.State of Ny Notified  + (03002618)
• PNO-II-99-038, on 990929,licensee RSO Notified NRC Operations Ctr of Diagnostic Misadministration That Had Occurred on 990928.Patient Was Given 2.76 Mci of I-131 for Whole Body Diagnostic Scan Rather than Prescribed 2.0 Mci  + (03002631)
• PNO-III-90-027, on 900410,glass Syringe Vial Containing 1 Mci P-32 Reported Missing.Lead Pig Was Wipe Tested on 900406 & Returned to Original Shipping Package.Search Being Conducted.Region III Monitoring Search.State Notified  + (03002639)
• PNO-III-98-050, on 981027,patient Being Treated for Uterine Cancer Received 5,000 Centigray Dose Instead of Prescribed 4,000 Centigray Dose.Caused by Calculational Error & Computer Program Error  + (03002640)
• PNO-III-98-010, on 980123,Maimi Valley Hosp Received Package Containing 60 Mci Ir-192 in Form of 66 Seeds.Excessive Radiation Level Found on Top of Package.Caused by Shifting from Stored Position  + (03002643)
• PNO-III-98-043, on 980904,licensee Reported Potential Discrepancy Between Dose Calibrator Measurements & Liquid Scintillation Counter Measurements Indicating Dose Administered to Patient Less than 20% of Prescribed Dose  + (03002649)
• PNO-III-91-019, on 910415-18,licensee Reported That Patient Who Underwent Brachytherapy Treatment for Tracheal Cancer Received Radiation Dose 32% Lower than Perscribed  + (03002649)
• PNO-III-97-041, on 970508,contaminated Package Exceeds NRC Requirements Occurred.Radioactive Contaminant Determined to Be Tc-99m.All Subsequent Contamination Wipes of Packages Found No Addl Contamination  + (03002665)
• PNO-III-98-034, on 980610,minor Radioactive Contamination Occurred While Patient Treated in Emergency Room.Puddle of Urine & Blood Noticed in Patient Room Which Was Contaminated with I-131 Due to Patient Previous Treatment with I-131  + (03002665)
• PNO-III-94-005, on 940118,Region III Received Two Ltrs & 940113,from Licensee Reporting Misadministration of Na I-131 Which Patient May Have Received Dosage 48% Greater than Prescribed  + (03002665)
• PNO-III-93-011, on 930226,therapeutic Misadministration Which Occurred 920212 Was Identified During Audit of Therapeutic Medical Procedures.Patient Received 32 Percent Overdose of Rads for Cancer Treatment.Special Insp Will Be Done  + (03002669)
• PNO-III-88-063, on 880711,licensee Reported Female Patient Received Therapeutic Dose of Radiation About 18% Over That Prescribed.No Adverse Reactions Expected.Patient Physician Will Be Informed  + (03002685)
• PNO-III-86-137, on 861119,licensee Reported That Patient Administered 20 Mci I-131 Instead of 20 Mci Tc-99m Mdp.Insp Scheduled for Early Next Wk to Review Circumstances of Misadministration  + (03002685)

• PNO-III-85-051, on 850619,patient Received 14,000 Rads to Chest Area Instead of 5,000 Rads During Treatment w/120 Mci Ir-192 for Lung Cancer.Caused by Dose Miscalculation.Patient Released W/No Observable Ill Effects  + (03002725)
• PNO-III-92-034, on 920609,licensee Reported That Patients Postrate Gland Received Approx 42% of Intended Radiation Dose & Tissues Surrounding Prostate Received Greater than Anticipated Radiation Dose on 920529  + (03002725)

• PNO-III-88-004, on 880120,package Containing Two Vials of Liquid P-32 Disappeared After Purchasing Dept Staff Member Placed Package in Hosp Purchasing & Receiving Area.Region III Investigating Incident.Licensee Will Submit Loss Rept  + (03002745)
• PNO-III-98-019, on 980219,brachytherapy Treatment of Patient Using Vaginal Cs-137 Implant Was Terminated Prematurely. Nurse Found Applicator on Floor Beside Patient Bed.Device Apparently Removed by Patient  + (03002745)
• PNO-III-89-056, on 890824,licensee Reported That Research Lab Closed Pending Decontamination.Licensee Contractor to Audit Radiation Safety Program,Including Surveys of 50 of Univ Research Labs  + (03002764)
• PNO-III-93-058, on 931006,licensee Was Not Able to Locate Medical Treatment Device,Called Eye Applicator,Containing Sealed Source of 20 Mci of Sr-90.Licensee Plans to Interview Security & Housekeeping Staffs in Effort to Locate Source  + (03002764)
• PNO-IV-90-043, on 901207,diagnostic Dose of I-131 & Tc-99m Administered to Pregnant Patient for Thyroid Uptake & Scan. Licensee Completing Dose Assessment for Fetus & Will Rept Results to Region IV by 901210  + (03002872)
• PNO-IV-93-022, licensee Reported Administered Diagnostic Dose of NaI-131 to Female Patient Who Had Been Scheduled for Tc-99m Bone Scan.Patient Was Administered Ipecac to Induce Vomiting.Region IV Was Notified of Occurrence on 930727  + (03002893)
• ML18204A369  + (03002902)
• ML18204A365  + (03002902)
• PNO-IV-98-014, on 980403,licensee RSO Provided Telephonic Notification to NRC Headquarters Operation Ctr of Discovery of Damaged Exit Sign.Worker Immediately Left Area When Discovery Made & Contacted Rso.Region IV Informed NMSS  + (03002902)
• PNO-IV-97-036, on 970616,licensee Began Brachytherapy Procedure to Treat Patient for Cervical Cancer.Licensee Calculated That Patient May Have Received Max Dose of 400-500 Millirads to Skin  + (03002912)
• PNO-IV-97-057, on 971017,radiation Safety Officer Inquired Re Reportability of Brachytherapy Incident at Facility in Oct 1997.Patient Removed Source Prior to Scheduled Completion of Treatment  + (03002921)
• PNO-IV-96-071, on 961219,Region IV Walnut Creek Field Ofc Was Notified of Misadministration Involving Administration of I-131.Uptake Measurement Needed to Assist Authorized User in Determining Dosage Required to Treat Patient  + (03002935)
• PNO-I-91-014, on 910214-18,therapeutic Misadministration Occurred w/I-125.Physicist Noticed Error Occurred on 910218 & Retrieved Patient Data for Review.Review of Data Confirmed Error.Appropriate Actions Taken  + (03002959)
• PNO-I-98-031, on 980721,RSO Notified Region I That Two I-125 Seeds Unaccounted for Following Permanent Seed Implant Into Patient Prostate Gland.Region I Staff Will Followup on Licensee Evaluations & Corrective Action  + (03002976)
• PNO-V-95-025B, on 950203,misadminstration Involving Manual Brachytherapy Treatement Using iradium-192 Occurred. State of Washington Will Be Informed  + (03003003)
• IR 05000628/2008008  + (03003137)
• PNO-II-90-003, on 900107,radioactive Trash Containing Approx 1 Mci I-131 Removed from Patient Room & Incinerated on 900108.Ash Samples Obtained on 900109 Indicated No Detectable Activity.State of CA Informed  + (03003230)
• ML18218A110  + (03003231)
• ML18215A402  + (03003231)
• PNO-IV-88-010, on 880204,therapy Misadministration of P-32 Discovered.Physician Prescribed 4.0 Mci P-32 for Treatment of Polycythemia Vera (Excess Blood Platelets).Caused by Technologist Error.No Adverse Patient Effects Expected  + (03003233)
• ML18199A601  + (03003249)
• ML18199A590  + (03003249)
• PNO-IV-88-056, on 880708,licensee Discovered That Cs-137 Brachytherapy Sealed Source Removed from Patient Undergoing Gynecological Treatment to Be 30 Mg Instead of Intended 20 Mg.Caused by Personnel Error  + (03003249)
• PNO-IV-96-055, on 961010,licensee Reported Loss of 130 Uci Am-241 Source.Determined Packard Scintillation Counter Was Transferred to Scrap Dealer in Feb 1996.Licensee Contacted Scrap Dealer for Info Re Final Disposition  + (03003255)