PNO-V-93-007, on 930211,patient Forcibly Removed Cervical Applicator Containing Four Cs-137 Sources Totalling 130 Mci. RSO Does Not Believe Any Member of Medical Staff Received Exposure in Excess of Regulatory Limits

PNO-V-93-007:on 930211,patient Forcibly Removed Cervical Applicator Containing Four Cs-137 Sources Totalling 130 Mci. RSO Does Not Believe Any Member of Medical Staff Received Exposure in Excess of Regulatory Limits

ML20197C421
Person / Time
Site:	03013337
Issue date:	02/11/1993
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
To:
References
PNO-V-93-007-01, PNO-V-93-7-1, NUDOCS 9712240185
Download: ML20197C421 (1)

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Tbbruary 11, 1993.dELIKIMARY NOTIFICATION OF EVENT OR U. HUB 11AL_Qfd3lRREHCE Pilo-V-93-007 This preliminary notif cation constitutes EARLY notice of events of POSSIBLE cafety or public interest significance. The information is as initially received without verification or evaluation, and is basically all that is known by the Region V starf on this dato.

Facility Licensee _Emeroonov Classification Kuakini Medical contor tiotification of Unusual Event Honolulu, Hawaii Alert Dockets: 03013337 License Not 53-17797-01 Site Area Emergency General Emergency X Not Applicable Subject DRACHYTHERAPY INCIDENT d

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Medical Conter, located in Honolulu, Hawaii,fficas (RSO) on February 11, 1993, the Radiation Safety O fr The Queen's ScalGd a Regis

/ Senior Health Physicist to discuss the reportabilitysof -gp incident involving cesiom-137 brachytherapy sources. The Queen'aAMedical Conter provides contractual medical physics services for the Euakirti Medical Center in Honclulu. Last night a female patient g the Kuakf61 Medical Center

_ forcibly removed from herself a FletcTer-Suiticer d pal applicator tntaining four cesium-137 sources totalling 130 millicurios. A shift arue discovered the applicator containing the sources lying on the bed between the patient's legs about 20 minutes after the last patient check by 6.he nurse which had revealed normal conditions. Due to the patient's intervention, the treatment time was approximately 15% short of the planned 68 hours7.87037e-4 days <br />0.0189 hours <br />1.124339e-4 weeks <br />2.5874e-5 months <br /> prescribed. The NMSS staff was consulted concerning this incident and it was determined that no reportabla misadministration had occurred due to the patient's intervention.

All sources have been accounted for and the RSO is aggressively investigating the incident. The two attending nurses woro wearing personal dosimetry. A digital dosimeter worn by one nurse road 0.1 mrem following the incident and was the highest dose recorded. At this time the RSO does not beliao any member of the medical center staff received an exposuro in excess of the regulatory limits. The dose to the patient's thigh is being ovaluated by the licensee's medical physicist.

Region V rocoived initial notification of this incident from another licensee's Radiation Safety Officer at 2:00 PM, PST, February 11, 1993.

The information prosented heroin has been discussed with the licensee's representativo, and is current as of 4:00 PM, PST, February 11, 1993.

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This preliminary notification is issued for information only. Region V

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health physics inspectors currently in Hawaii will be contacted and

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directed to review the licensee's initial actions to investigato this /2 8 M 1-incident.

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