PNO-IV-97-029, on 970518,patient Removed 2 of 17 Ribbons Containing Ir-192 Seeds from Vaginal Treatment Site & Placed Them on Her Chest.Patient Intervention Observed by Assistant RSO on Closed Circuit Television.State of Wa Informed: Difference between revisions

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: g.                                                                                                     1 C
g.
May 20,1997 PRELIMINARY NOTIFICATION OFfVGNT OR UNUSUAL OCCURRENCE PNO-IV-97-029
1 C
,          This preliminary notification constitutes 'EARLY notice of events of POSSIBLE safety or public interest significence. The information is as initially received without verification or evaluation, and is basically all that is known by Region IV staff in Arlington, Texas on this date.
.,. May 20,1997 PRELIMINARY NOTIFICATION OFfVGNT OR UNUSUAL OCCURRENCE PNO-IV-97-029 This preliminary notification constitutes 'EARLY notice of events of POSSIBLE safety or public interest significence. The information is as initially received without verification or evaluation, and is basically all that is known by Region IV staff in Arlington, Texas on this date.
Facility                           Licensee Emeroency Classification Madigan Army Med Center, Tacoma, Wa                 Notification of Unusual Event Madigan Army Med Center, Tacoma, Wa                 Alert Tacoma, Washington 98431 5000                     Site Area Emergency                           <
Facility Licensee Emeroency Classification Madigan Army Med Center, Tacoma, Wa Notification of Unusual Event Madigan Army Med Center, Tacoma, Wa Alert Tacoma, Washington 98431 5000 Site Area Emergency Dockets: 03003368 License No: 46-02645-03 General Emergency X Not Applicable
Dockets: 03003368 License No: 46-02645-03             General Emergency X Not Applicable


==Subject:==
==Subject:==
POSSIBLE BRACHYTHERAPY MISADMINISTRATION At approximately C       p.m. on May 18,1997, a patient removed 2 of 17 ribbons containing iridium 182 seeds from the vaginal treatment site and placed them on her             ,
POSSIBLE BRACHYTHERAPY MISADMINISTRATION At approximately C p.m. on May 18,1997, a patient removed 2 of 17 ribbons containing iridium 182 seeds from the vaginal treatment site and placed them on her chest (The ribbons were inserted in a template during the treatment to maintain the l
chest (The ribbons were inserted in a template during the treatment to maintain the             l desired source geometry.) At the time the ribbons were removed, the patient had completed 72 hours of a planned 85-hour treatment. The " patient intervention" was observed by the Assistant Radiation Safety Officer (ARSO) on a closed circuit television.
desired source geometry.) At the time the ribbons were removed, the patient had completed 72 hours of a planned 85-hour treatment. The " patient intervention" was observed by the Assistant Radiation Safety Officer (ARSO) on a closed circuit television.
The ARSO immediately responded and entered the patient's room, removed the 2 ribbons from the patient's chest using long handled tongs and placed the ribbons in a shielded container located in the room. The licensee estimated the ribbons remained on the patient's chest no more than 30 seconds. The authorized user physician was summoned to the hospital and by 11:25 p.m., May 18th, the authorized user ceased further treatment by removing all remaining sources from the patient. As of its initial contact with the NRC, the licensee had not yet determined if this incident constituted a misadministration.
The ARSO immediately responded and entered the patient's room, removed the 2 ribbons from the patient's chest using long handled tongs and placed the ribbons in a shielded container located in the room. The licensee estimated the ribbons remained on the patient's chest no more than 30 seconds. The authorized user physician was summoned to the hospital and by 11:25 p.m., May 18th, the authorized user ceased further treatment by removing all remaining sources from the patient. As of its initial contact with the NRC, the licensee had not yet determined if this incident constituted a misadministration.
Region IV will dispatch an inspector to the licensee's medical center this week. Region IV has notified NMSS.
Region IV will dispatch an inspector to the licensee's medical center this week. Region IV has notified NMSS.
Region IV received notification of this occurrence by telephone from the licensee's Radiation Safety Officer at 3:45 p.m., (PDT), May 19,1997. The licensee was instructed by the Region IV Walnut Creek Field Office to report the incident to the Headquarters Operations Center. The NRC Operations Center was notified of the event at approximately 8 p.m. (EDT).
Region IV received notification of this occurrence by telephone from the licensee's Radiation Safety Officer at 3:45 p.m., (PDT), May 19,1997. The licensee was instructed by the Region IV Walnut Creek Field Office to report the incident to the Headquarters Operations Center. The NRC Operations Center was notified of the event at approximately 8 p.m. (EDT).
i The State of Washington has been informed.                                                       !
i The State of Washington has been informed.
                                                                                                          ~
This information has been discussed with the licensee and is current as of 5:30 p.m.
I This information has been discussed with the licensee and is current as of 5:30 p.m.
~
(PST), May 19,1997.
(PST), May 19,1997.


==Contact:==
==Contact:==
FRANK WENSLAWSKI               JIM MONTGOMERY (51u)975-0249         (510)975-0249 9705200396 970520                                                                           j   i M-I         7-029 PDR                                                                   \0      ,
FRANK WENSLAWSKI JIM MONTGOMERY (51u)975-0249 (510)975-0249 9705200396 970520 i
l}}
j
\\0 M-I 7-029 PDR
.}}


{{PNO-Nav|region=IV}}
{{PNO-Nav|region=IV}}

Latest revision as of 16:29, 11 December 2024

PNO-IV-97-029:on 970518,patient Removed 2 of 17 Ribbons Containing Ir-192 Seeds from Vaginal Treatment Site & Placed Them on Her Chest.Patient Intervention Observed by Assistant RSO on Closed Circuit Television.State of Wa Informed
ML20141E295
Person / Time
Site: 03003368
Issue date: 05/20/1997
From: Jonathan Montgomery, Wenslawski F
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:
References
PNO-IV-97-029, PNO-IV-97-29, NUDOCS 9705200396
Download: ML20141E295 (1)
v • d • e


_

g.

1 C

.,. May 20,1997 PRELIMINARY NOTIFICATION OFfVGNT OR UNUSUAL OCCURRENCE PNO-IV-97-029 This preliminary notification constitutes 'EARLY notice of events of POSSIBLE safety or public interest significence. The information is as initially received without verification or evaluation, and is basically all that is known by Region IV staff in Arlington, Texas on this date.

Facility Licensee Emeroency Classification Madigan Army Med Center, Tacoma, Wa Notification of Unusual Event Madigan Army Med Center, Tacoma, Wa Alert Tacoma, Washington 98431 5000 Site Area Emergency Dockets: 03003368 License No: 46-02645-03 General Emergency X Not Applicable

Subject:

POSSIBLE BRACHYTHERAPY MISADMINISTRATION At approximately C p.m. on May 18,1997, a patient removed 2 of 17 ribbons containing iridium 182 seeds from the vaginal treatment site and placed them on her chest (The ribbons were inserted in a template during the treatment to maintain the l

desired source geometry.) At the time the ribbons were removed, the patient had completed 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> of a planned 85-hour treatment. The " patient intervention" was observed by the Assistant Radiation Safety Officer (ARSO) on a closed circuit television.

The ARSO immediately responded and entered the patient's room, removed the 2 ribbons from the patient's chest using long handled tongs and placed the ribbons in a shielded container located in the room. The licensee estimated the ribbons remained on the patient's chest no more than 30 seconds. The authorized user physician was summoned to the hospital and by 11:25 p.m., May 18th, the authorized user ceased further treatment by removing all remaining sources from the patient. As of its initial contact with the NRC, the licensee had not yet determined if this incident constituted a misadministration.

Region IV will dispatch an inspector to the licensee's medical center this week. Region IV has notified NMSS.

Region IV received notification of this occurrence by telephone from the licensee's Radiation Safety Officer at 3:45 p.m., (PDT), May 19,1997. The licensee was instructed by the Region IV Walnut Creek Field Office to report the incident to the Headquarters Operations Center. The NRC Operations Center was notified of the event at approximately 8 p.m. (EDT).

i The State of Washington has been informed.

This information has been discussed with the licensee and is current as of 5:30 p.m.

~

(PST), May 19,1997.

Contact:

FRANK WENSLAWSKI JIM MONTGOMERY (51u)975-0249 (510)975-0249 9705200396 970520 i

j

\\0 M-I 7-029 PDR

.

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