ENS 45579: Difference between revisions
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| event date = 12/15/2009 EST | | event date = 12/15/2009 EST | ||
| last update date = 12/17/2009 | | last update date = 12/17/2009 | ||
| title = Agreement State Report - Possible Misadministration | | title = Agreement State Report - Possible Misadministration of Radioactive Medical Treatment | ||
| event text = The following report was received via facsimile: | | event text = The following report was received via facsimile: | ||
[Tennessee Division of Radiological Health] TN DRH was notified on 12/15/09, by the medical physicist at Cookeville Regional Medical Center, of a possible therapeutic misadministration that occurred the morning of 12/15. A patient was being treated with three sealed sources of cesium-137 (total activity of 70 mg Ra-equivalent) contained in a vaginal applicator. The patient was elderly and heavily sedated. The applicator was inserted and after twenty minutes of treatment, the nurse came into the room to check on the patient and noticed the applicator outside the treatment area. The applicator was removed and placed in a lead pig. The patient may have received a maximum dose of 76 Rem to the thigh area. A written report will be submitted by the licensee. | [Tennessee Division of Radiological Health] TN DRH was notified on 12/15/09, by the medical physicist at Cookeville Regional Medical Center, of a possible therapeutic misadministration that occurred the morning of 12/15. A patient was being treated with three sealed sources of cesium-137 (total activity of 70 mg Ra-equivalent) contained in a vaginal applicator. The patient was elderly and heavily sedated. The applicator was inserted and after twenty minutes of treatment, the nurse came into the room to check on the patient and noticed the applicator outside the treatment area. The applicator was removed and placed in a lead pig. The patient may have received a maximum dose of 76 Rem to the thigh area. A written report will be submitted by the licensee. | ||
Latest revision as of 22:10, 1 March 2018
| Where | |
|---|---|
| Cookeville Regional Medical Center Cookeville, Tennessee (NRC Region 1) | |
| License number: | R-71026-D10 |
| Organization: | Tennessee Div Of Rad Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+53.98 h2.249 days <br />0.321 weeks <br />0.0739 months <br />) | |
| Opened: | Debra Shults 10:59 Dec 17, 2009 |
| NRC Officer: | Dong Park |
| Last Updated: | Dec 17, 2009 |
| 45579 - NRC Website | |