View source for PNO-III-99-004, on 990128,patient Apparently Removed Ribbon Containing Ir-192 Seeds During Radiation Therapy Procedure. Ribbon Had Been Inserted Through Patient Nose & Into Lungs for Treatment of Lung Cancer.Treating Physician Notified

{{Adams
| number = ML20202D529
| issue date = 02/01/1999
| title = PNO-III-99-004:on 990128,patient Apparently Removed Ribbon Containing Ir-192 Seeds During Radiation Therapy Procedure. Ribbon Had Been Inserted Through Patient Nose & Into Lungs for Treatment of Lung Cancer.Treating Physician Notified
| author name = Madera J, Mulay S
| 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-99-004, PNO-III-99-4, NUDOCS 9902020016
| 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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                   -    .                                         February  1, 1999 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-III-99-004 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. Illino.s) on this date.
Facility                                       Licensee Emergency Classification Detroit Macomb Hospital                          Notification of Unusual Event Detroit Macomb Hospital                          Alert Detroit. Michigan                                Site Area Emergency License No: 21-01190-05                          General Emergency                     ;
X Not Applicable                       ;
a .                                                                                          1

==Subject:==
MEDICAL EVENT On January 28 1999, a patient apparently removed a ribbon containing 15 iridium-192 seeds during a radiation therapy procedure. The ribbon had been inserted through the patient's nose and into the lungs for treatment of lung cancer,                                                                      j 1
The prescribed radiation dose was 1,700 centigray over a treatment period             !
of 22 hours According to the licensee, the patient apparently moved the ribbon after 48 minutes of the treatment. As a result, the treatment area received a radiation dose of 62.1 centigray. The dislodged ribbon
           . delivered a dose of about 15.5 centigray to the patient's nasal passage over about a 12 minute period. The nursing staff noticed the partially dislodged ribbon approximately 3 minutes after the apparent intervention and summoned the licensee's Radiation Safety Officer who removed the                   l ribbon.                                                                               !
The patient and treating physician were notified. No adverse consequences             I are expected as a result of the radiation dose to the unintended area of
          .the nasal passage.
          ~ NRC Region III (Chicago) will review the event during an inspection to be scheduled in the next several weeks.
The State of Michigan has been informed. The information in this
          . preliminary. notification has been reviewed with the licensee.
The licensee notified the NRC 03erations Center of this event at 11:48 a.m.;EST on January 29, 1999. T11s information is current as of 8:59 a.m.             ,
EST on February 1, 1999.

==Contact:==
Sam Mulay               John Madera (630)829-9837          (630)829-9834 99 py20g16990201                                                              g PND-III-99-OO4PDRTh i
010037
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