PNO-III-98-054, on 981006,medical Event Involving Dose to Fetuses Occurred.Licensee Received Verbal Confirmation from Patient That She Was Not Pregnant,Prior to Administering Dose.Licensee Notified Referring Physician of Event
| ML20155F215 | |
| Person / Time | |
|---|---|
| Site: | 03002310 |
| Issue date: | 11/04/1998 |
| From: | Jamnes Cameron, Wright G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| References | |
| PNO-III-98-054, PNO-III-98-54, NUDOCS 9811050353 | |
| Download: ML20155F215 (1) | |
November 4, 1998 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-III-98-054 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 Region III staff (Lisle, Illinois) on this date.
Facility Licensee Emergency Classification St. Joseph Health Center Notification of Unusual Event Kansas City, Missouri Alert License No: 24-02704-01 Site Area Emergency General Emergency X Not Applicable i
Subject:
MEDICAL EVENT INVOLVING DOSE TO FETUSES (TWINS)
On November 4,1998, the licensee notified NRC of a medical event that occurred at the licensee's facilities in Kansas City, Missouri. On October 6, 1998, the licensee administered 150 millicuries (5.56 gigabecquerels) of sodium iodide-131 to a female Jatient. Prior to administering the dose, the licensee received ver]al confirmation from the patient that she was not pregnant.
A] proximately three and one-half hours after administering the dosage to t1e patient, the referring physician notified the licensee of a positive pregnancy test that he had ordered, unbeknownst to the licensee. At the time of the I-131 administration, the patient was 12 weeks ) regnant with twins. Immediately upon notification of the test results, tie licensee attempted to minimize the radiation exposure to the fetuses by increasing the patient's fluid intake.
The licensee contacted two local (Kansas City, Missouri) physicists for assistance in calculating the dose to the fetuses and the fetal thyroids.
The licensee also contacted a pediatric endocrinologist in Oak Ridge, Tennessee, for assistance. The licensee estimated a total effective dose equivalent of 38 rems (0.38 Sievert) to each fetus. At this time, the licensee does not have an estimate for the fetal thyroid doses.
The licensee notified the referring physician of the event. The licensee notified the patient and her spouse of the medical event.
The State of Missouri and the NRC Office of Nuclear Materials Safety and Safeguards have been notified. The information in this preliminary notification has been reviewed with the licensee.
NRC Region III (Chicago) plans to conduct an inspection on November 6, 1998, to review the circumstances surrounding this event. An NRC medical consultant will be obtained to review the event.
The licensee notified NRC Region III of this event at 10:45 a.m.(CT)on November 4,1998, a id planned to contact the NRC Operations Center of this event. This information is current as of 2:15 p.m.(CT) on November
- 4. 1998.
Contact:
JAMNES CAMERON GEOFFREY WRIGHT 4
g h)U '
(630)829-9833 (630)829-9602 j
t 9811050353 981104
\\.
E-Il$98-054PDRl