PNO-IV-93-019, on 930610,therapeutic Misadministration Incident Occurred Involving Omnitron High Dose Rate Therapy Unit.Treatment Stopped When Noticed Catheter in Wrong Position.Written Misadminstration Rept Will Be Provided
| ML20045B935 | |
| Person / Time | |
|---|---|
| Site: | 03028641 |
| Issue date: | 06/15/1993 |
| From: | Cain C, Mclean L NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| References | |
| PNO-IV-93-019, PNO-IV-93-19, NUDOCS 9306210285 | |
| Download: ML20045B935 (1) | |
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- June 15, 1993 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-IV-93-019 This preliminary notification constitutes EARLY riotice 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 the Region IV staff on this date.
Facility Licensee Emergency Classification Department of The Air Force Notification of Unusual Event Keesler Air Force Base Alert Department of the Air Force Site Area Emergency San Antonio, Texas 78235 General Emergency Dockets: 03028641 License No: 42-23539-01AF X Not Applicable
Subject:
THERAPEUTIC MISADMINISTRATION The licensee reported an incident that occurred at Keesler Air Force Base, Biloxi, Mississippi, on June 10, 1993. During an endobronchial treatment using an Omnitron High Dose Rate (HDR) therapy unit, one of the two catheters used for the treatment was found not to be at the planned extension length. The second catheter was programmed for 150.5 centimeters (cm); however, the computer did not accept this length and defaulted to 100 cm. The default length was displayed on the screen but was not immediately noticed by the licensee. Treatment was terminated when the licensee recognized the catheter's wrong position.
The licensee determined that the source stopped outside of the body for 46.1 seconds at the 100 cm default catheter position. The Omnitron HDR source activity was 3.5 curies of iridium-192.
At the time of the report, the licensee had not determined whether this incident was a misadministration. After consultation with NMSS, Region IV notified the licensee that the incident was to be classified as a therapeutic misadministration as defined in 10 CFR 35.2. The licensee will provide Region IV with a written misadministration report. The patient has been notified by the licensee.
The offices of NMSS and Region II have been informed.
Region IV received notification of this occurrence by telephone from the licensee on June 14, 1993.
This information has been confirmed with a licensee representative.
Contact:
M. Linda McLean Charles L. Cain (817)860-8116 (817)860-8186 i
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