ENS Event | |
|---|---|
22:00 Sep 25, 2001 | |
| Title | Medical Misadministration Due to Improper Positioning of Implant Device |
| Event Description | Abstract - Female patient undergoing vaginal implant therapy on September 25, 2001. 'T-bomb' applicator loaded with 3 Cs-137 sources, each 19.73 mg RaEq [milligram Radium Equivalent] (49.92 mCi each, total activity 149.75 mCi). Implant performed 8:30 AM on 9/25/01. Status of implant placement made by nurse at 10:42 AM, and again at 2:10 PM. When physician checked patient at 5:00 PM on 9/25/01, implant was found outside of patient adjacent to her vaginal area. Physician did not report incident to Radiation Safety Officer, thus Licensee did not report incident to State. Estimate of total absorbed dose to the surface of the affected area was 7.55 Gy [Gray], this includes a dose of 0.74 Gy that comes from the normal implant itself.
Consequence of exposure - Tissue necrosis in affected area. The cause of the misadministration is still under investigation. A contributing factor was the failure to periodically check the implant placement. The patient was informed. |
| Where | |
|---|---|
| North Shore Medical Center Salem, Massachusetts (NRC Region 1) | |
| License number: | 44-0161 |
| Organization: | Ma Radiation Control Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+27855.12 h1,160.63 days <br />165.804 weeks <br />38.156 months <br />) | |
| Opened: | Robert Gallaghar 14:07 Nov 29, 2004 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Nov 29, 2004 |
| 41230 - NRC Website | |
North Shore Medical Center with Agreement State | |
WEEKMONTHYEARENS 412302001-09-25T22:00:00025 September 2001 22:00:00
[Table view]Agreement State Medical Misadministration Due to Improper Positioning of Implant Device 2001-09-25T22:00:00 | |