PNO-III-87-112, patient Received Therapeutic Radiation Exposure of 500 Rads to Wrong Hip.Patient Unharmed.Caused During Pretreatment Planning When Technologist Inadvertently Placed Treatment Marks on Wrong Hip: Difference between revisions
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{{#Wiki_filter:PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE--PNO-III-87-112 | {{#Wiki_filter:PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE--PNO-III-87-112 Date 08/25/87 30~ / 9() | ||
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 the Region III staff on this date. | 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 the Region III staff on this date. | ||
i Facility: | i Facility: | ||
2500 East State Blvd. | Parkview Memorial Hospital Licensee Emergency Classification: | ||
2500 East State Blvd. | |||
_X,_not Applicable | Notification of an Unusual Event Fort Wayne, Indiana Alert | ||
~ | |||
License No. 13-01284-03 | |||
__TJiteAreaEmergency Nneral Emergency | |||
_X,_not Applicable l | |||
==Subject:== | ==Subject:== | ||
THERAPEUTIC MISADMINISTRATION On August 24, 1987, the Licensee notified Region III (Chicago) that a 75 year old male patient had received a therapeutic radiation exposure (500 rads) to the wrong hip. | THERAPEUTIC MISADMINISTRATION On August 24, 1987, the Licensee notified Region III (Chicago) that a 75 year old male patient had received a therapeutic radiation exposure (500 rads) to the wrong hip. | ||
The patient was to receive 250 rads / day to the right hip; however, during the pre-treatment planning (simulation) a technologist inadvertently placed treatment marks on the patients left hip rather than the right side. The patient was then taken to the therapy room where another technologist noted the treatment marks on the left hip area and treated the left hip area. Prior to the third (3rd) treatment day, the patient advised the technologist that they were treating the wrong hip. The technologist then checked the patient's chart and | The patient was to receive 250 rads / day to the right hip; however, during the pre-treatment planning (simulation) a technologist inadvertently placed treatment marks on the patients left hip rather than the right side. The patient was then taken to the therapy room where another technologist noted the treatment marks on the left hip area and treated the left hip area. | ||
Prior to the third (3rd) treatment day, the patient advised the technologist that they were treating the wrong hip. The technologist then checked the patient's chart and j | |||
realized that the wrong hip was treated. | |||
(The treatments were halted when this error was discovered on August 24,1987.) | (The treatments were halted when this error was discovered on August 24,1987.) | ||
The patient has been examined by a physician, and no clinical side effects were noted. | The patient has been examined by a physician, and no clinical side effects were noted. | ||
| Line 30: | Line 36: | ||
The State of Indiana will be notified. | The State of Indiana will be notified. | ||
Region III was notified of the misadministration at 4:30 p.m. (CDT), August 24, 1987. This information is current as of 8 a.m., August 25, 1987. | Region III was notified of the misadministration at 4:30 p.m. (CDT), August 24, 1987. This information is current as of 8 a.m., August 25, 1987. | ||
CONTACT: | CONTACT: | ||
D. | |||
man W. A FTS 388-5616 FTS 388-5512 | |||
)" | |||
1 I | 1 I | ||
1 DISTRIBUTION: | 1 DISTRIBUTION: | ||
H. St. | H. St. | ||
ACRS | ED0 NRR E/W Willste Mail: ADM:DMB Chairman Zech PA IE NMSS DOT:Trans only Comm. Roberts ELD OIA RES Comm. Bernthal AE00 NRC Ops Ctr Comm. Carr I | ||
CA | Comm. Rogers ACRS SP _ | ||
PHO-III-87-112 PDR | Regional Offices SECY | ||
) | |||
CA INP0 NSAC PDR RIII Resident Office Licensee: | |||
(Corp. Office - Reactor Lic. Only) 8708310133 870825 18(E Ol Region III | |||
-ggl[ | |||
PDR PHO-III-87-112 PDR Rev. August 1987 | |||
} | |||
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{{PNO-Nav|region=III}} | {{PNO-Nav|region=III}} | ||
Latest revision as of 06:02, 2 December 2024
| ML20238A579 | |
| Person / Time | |
|---|---|
| Site: | 03000190 |
| Issue date: | 08/25/1987 |
| From: | Axelson W, Wiedeman D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| References | |
| PNO-III-87-112, NUDOCS 8708310133 | |
| Download: ML20238A579 (1) | |
PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE--PNO-III-87-112 Date 08/25/87 30~ / 9()
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 the Region III staff on this date.
i Facility:
Parkview Memorial Hospital Licensee Emergency Classification:
2500 East State Blvd.
Notification of an Unusual Event Fort Wayne, Indiana Alert
~
License No. 13-01284-03
__TJiteAreaEmergency Nneral Emergency
_X,_not Applicable l
Subject:
THERAPEUTIC MISADMINISTRATION On August 24, 1987, the Licensee notified Region III (Chicago) that a 75 year old male patient had received a therapeutic radiation exposure (500 rads) to the wrong hip.
The patient was to receive 250 rads / day to the right hip; however, during the pre-treatment planning (simulation) a technologist inadvertently placed treatment marks on the patients left hip rather than the right side. The patient was then taken to the therapy room where another technologist noted the treatment marks on the left hip area and treated the left hip area.
Prior to the third (3rd) treatment day, the patient advised the technologist that they were treating the wrong hip. The technologist then checked the patient's chart and j
realized that the wrong hip was treated.
(The treatments were halted when this error was discovered on August 24,1987.)
The patient has been examined by a physician, and no clinical side effects were noted.
Region III will dispatch an inspector to review the circumstances of the misadministration.
An NRC medical consultant will be retained to review the medical aspects of the case.
The State of Indiana will be notified.
Region III was notified of the misadministration at 4:30 p.m. (CDT), August 24, 1987. This information is current as of 8 a.m., August 25, 1987.
CONTACT:
D.
man W. A FTS 388-5616 FTS 388-5512
)"
1 I
1 DISTRIBUTION:
H. St.
ED0 NRR E/W Willste Mail: ADM:DMB Chairman Zech PA IE NMSS DOT:Trans only Comm. Roberts ELD OIA RES Comm. Bernthal AE00 NRC Ops Ctr Comm. Carr I
Regional Offices SECY
)
CA INP0 NSAC PDR RIII Resident Office Licensee:
(Corp. Office - Reactor Lic. Only) 8708310133 870825 18(E Ol Region III
-ggl[
PDR PHO-III-87-112 PDR Rev. August 1987
}
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