ENS Event | |
|---|---|
20:35 Apr 8, 2005 | |
| Title | Agreement State Report of Potential Medical Misadministration |
| Event Description | The following information was provided by the State of CA via e-mail (text in quotes):
At 12:35 pm [the] manager of the [Saddleback Memorial Hospital] Imaging Department contacted [the CA Radiological Health Branch] to report a therapy misadministration involving HDR and Ir-192. [The hospital manager] knew few details, other than to report that the source was apparently implanted 8 cm short of its desired location. At this time it is not known how much under treatment there was to the tumor site, nor how much exposure there was to healthy tissue. [It has] not been determined if this is a CA SS&D [Sealed Source and Device]. [The hospital manager] is obtaining this information and will be reporting it back, via fax, as soon as possible. [The CA Radiological Health Branch] has requested narrative as to flow of events. This form will be updated and forwarded to NRC Ops Center as information comes in. |
| Where | |
|---|---|
| Saddleback Memorial Hospital Laguna Hills, California (NRC Region 4) | |
| License number: | 2652-30 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+-2.88 h-0.12 days <br />-0.0171 weeks <br />-0.00395 months <br />) | |
| Opened: | Mark Pietz 17:42 Apr 8, 2005 |
| NRC Officer: | Bill Huffman |
| Last Updated: | Apr 8, 2005 |
| 41580 - NRC Website | |
Saddleback Memorial Hospital with Agreement State | |
WEEKMONTHYEARENS 415802005-04-08T20:35:0008 April 2005 20:35:00
[Table view]Agreement State Agreement State Report of Potential Medical Misadministration 2005-04-08T20:35:00 | |