PNO-III-86-135, on 861006-08,patient Mistakenly Exposed to 2,000 Rads Instead of Prescribed 1,200 Rads During Co-60 Treatment for Blood Disease.Caused by Personnel Error. Misadministration Will Be Reviewed by NRC: Difference between revisions

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{{Adams
#REDIRECT [[PNO-III-86-135, B:on 861006-08,radiation Therapy Misadministration Occurred.Caused by Miscalculation of Exposure Time for Each of Six Planned Treatment.Special NRC Medical Advisory Board Formed to Evaluate Case]]
| number = ML20214F903
| issue date = 11/17/1986
| title = PNO-III-86-135:on 861006-08,patient Mistakenly Exposed to 2,000 Rads Instead of Prescribed 1,200 Rads During Co-60 Treatment for Blood Disease.Caused by Personnel Error. Misadministration Will Be Reviewed by NRC
| author name = Axelson W, Wiedeman D
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
| addressee name =
| addressee affiliation =
| docket = 03000394
| license number =
| contact person =
| case reference number = FRN-52FR36942, RULE-PR-35
| document report number = AC65-1-077, AC65-1-77, AC65-77, PNO-III-86-135, NUDOCS 8611250476
| document type = PRELIMINARY NOTIFICATION OF EVENT OR OCCURRENCE (PNO,, TEXT-INSPECTION & AUDIT & I&E CIRCULARS
| page count = 1
}}
{{#Wiki_filter:PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE--PNO-III-86-135 Data Novemb2r 17, 986 This preliminary notification constitutes EARLY notice of events of POSSIBLE safety cr public interest significance. The information is as initially received without v;rification or evaluation, and is basically all that is known by the Region III staff on this date.
Facility: Cleveland Clinic Foundation              Licensee Emergency Classification:
9500 Euclid Avenue                            Notification of an Unusual Event Cleveland, OH                                Alert Site Area Emergency License No. 34-00466-02                      General Emergency X Not Applicable 4
Subj ct: THEPAPEUTIC MISADMINISTRATION The licensee reported that an elderly, terminally ill patient was exposed to 2000 rads of radiation rather than the prescribed 1200 rads while undergoing cobalt-60 teletherapy treatment for a blood disease.
The treatment, which covered the patient's upper torso, began October 6, 1986, and ended October 8, 1986. The error was discovered on November 11, 1986, but was not reported to the NRC until November 17, 1986. The delay was apparently due to the licensee's failure to realize that a misadministration of this type requires imediate notification.
Th3 excess exposure resulted from an error in the treatment calculations, and was discovered when the patient was admitted to the clinic with skin complications.
An NRC medical consultant has been notified and will promptly review the misadministration.
The hospital is required to submit a written report on the incident, including a description of correction actions, within 15 days of the initial report. Region III (Chicago) has scheduled an onsite inspection to review the incident.                                                      ,
Tha State of Ohio will be notified.
This infonnation is current as of 12:30 p.m. (CST), November 17, 1986.
h CONTACT:  W. # G. Weideman FTS 388-5616 W. L. Axelson FTS 388-5612 46b 0 \
DISTRIBUTION:
H. St.                    ED0        NRR        E/W          Willste      Mail: ADM:DMB Chairman Zech              PA                  IE            NMSS                    D0T:Trans only Com. Roberts                ELD                  OIA          RES Comm. Asselstine                                AE0D Com. Bernthal Com. Carr                  SP /,'.19      Regional Offices ACRS SECY                        INP0                NSAC                                                  ;
CA                          RIII Resident Office PDR                        Licensee:                      (Corp. Office - Reacter Lic. Only) gg    y $ 6 861118                                            Region III PNO-III-86-135 PDR                                            Rev. November 1985
                                                        .            .      _ - - -        -  _ - _    - -.}}
 
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