View source for PNO-III-98-024, on 970714,apparent Misadministration Occurred During Intrabronchial Brachytherapy Cancer treatment.Ir-192 Catheter Removed from Intended Site by Patient

{{Adams
| number = ML20199E579
| issue date = 03/10/1998
| title = PNO-III-98-024:on 970714,apparent Misadministration Occurred During Intrabronchial Brachytherapy Cancer treatment.Ir-192 Catheter Removed from Intended Site by Patient
| author name = Mitchell M, Wright G
| author affiliation = NRC OFFICE OF INSPECTION &amp; ENFORCEMENT (IE REGION III)
| addressee name = 
| addressee affiliation = 
| docket = 03002005
| license number = 
| contact person = 
| document report number = PNO-III-98-024, PNO-III-98-24, NUDOCS 9901210023
| document type = PRELIMINARY NOTIFICATION OF EVENT OR OCCURRENCE (PNO,, TEXT-INSPECTION &amp; AUDIT &amp; I&amp;E CIRCULARS
| page count = 1
}}
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March 10, 1998 PRELIMINARY NOTI.'ICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-III-98-024 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 III staff (Lisle, Illinois) on this date.
Facility                                                Licensee Emergency Classification DETROIT MACOMB HOSPITAL CORPORATION                      Notification of Unusual Event Detroit Macomb Hospital Corporation                     Alert Warren, Michigan                                         Site Area Emergency License No: 21-01190-05                                  General Emergency X   Not Applicable

==Subject:==
POSSIBLE MI3 ADMINISTRATION INVOLVING AN UNDERDOSE OF IRIDIUM-192 On March 5,                  1998, during a routine inspection at Detroit Macomb Hospital Corporation, Warren, Michigan, an NRC inspector identified a potential medical misadministration that had occurred on July 14, 1997, involving an underdose and a dose to a wrong treatment site.
i The apparent misadministration occurred during an intrabronchial                                                      [
brachytherapy cancer treatment to a patient. The prescribed dose for this                                             i treatment was 1502 rads (15.02 gray), and the dose received was 614.25                                                ;
rads (6.14 Gray). During treatment, a catheter containing 35.6                                                        >
mil 11 curies (1.32 gigabecquerel) iridium-192 seeds was inadvertently removed from the intended treatment site by the patient. Apparently, the patient pulled the catheter out when adjusting eye glasses or oxygen tubing, possibly during associated coughing. This resulted in a calculated dose of 103 rads (1.03 gray) to the skin of an unintended site.
The patient was notified immediately following discovery by the authorized user physician. The referring physician was notified verbally and in writing by the' authorized user physician. The licensee did not recognize the event to be a misadministration, however, the event was reported to the Radiation Safety Committee on July 21, 1997. The attending physician reported no adverse health effects to the patient as a result of this event.
The State of Michigan and the NRC Office of Nuclear Materials Safety and Safeguards have been notified. The information in this preliminary notification has been reviewed with licensee management.
The licensee reported the event to the NRC Operations Center at 2:10 p.m.
(EST) on March 6, 1998. This information is current as cf 10:00 a.m. on March 10, 1998.

==Contact:==
MARK W. MITCHELL            GEOFFREY C. WRIGHT (630)829-9855              (630)829-9602 9901210023 980310 "
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