PNO-III-91-019, on 910415-18,licensee Reported That Patient Who Underwent Brachytherapy Treatment for Tracheal Cancer Received Radiation Dose 32% Lower than Perscribed
| ML20024G948 | |
| Person / Time | |
|---|---|
| Site: | 03002649 |
| Issue date: | 04/25/1991 |
| From: | Grobe J, Slawinski W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| References | |
| PNO-III-91-019, PNO-III-91-19, NUDOCS 9105020232 | |
| Download: ML20024G948 (1) | |
_.
FREllMLNARY HOT!FICAT!0tl Of EVEllT OR UNUSUAL OCCURRENCE pri0o!!!-91-19 Date April 23, 1991 This preliminary notification constitutes EARLY notice of events of POS$!DLE 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 111 My staff on this date.
Facility: Cleveland Clinic Licensee Emergency Classification Foundation General Emergency Site Area Emergency Cleveland, OH Alert Unusual Event N/A X Docket No. 030-02649 License No. 34-00466 01
Subject:
THERAPEUTIC HISADMINISTRATION On A3ril 24, 1991, the licensee repcrted that a 49-year-old patient who underwent brac1ytherapy treatment for tracheal cancer received a radiation dose 32 percent lower than the dosage prescribed.
The patient was to receive a total dose of 3,000 rads over a 7i-hour period, April 15-18,1991, using an iridium-192 brachytherapy implant. The Satient actually received a tumor dose of 2,045 rads, approximately 32 percent less tian the prescribed dose.
The apparent misadministration occurred because the treatment dose calculations performed by the licensee were Lased on a tumor distance of I cm. instead of the prescribed distance of 1.5 cm. Consequently, the licensee ordered iridium-192 sources of a lower strength tbtn that required to deliver the prescribed dose from 1.5 cm.
The error was identified by the licensee on April 23, 1991, during a post-treatment review. The physician and the patient have been notified.
No further treatment is planned.
The licensee will submit a written report.
Region 111 (Chicago) will review the event during an upcoming inspection.
The State of Ohio has been notified.
The information in this Preliminary Notification has been reviewed with the licensee.
Region 111 was rotified of this misadministration at 3 p.m. on April 24, 1991. This information is current as of 9 a.m., April 25, 1991.
tQthb N
CONTACT:
W.
lawinski J. Grobe' 388-5618 388-5612 DISTRIBUTION:
HEADQUARTERS OFFICES REGIONS MAIL T0:
Chairman Carr HMSS Region f FCS(Orig)
Comm. Rogers GPA:SP Region 11 DOT (Trans.
Comm. Curtiss GPA:PA Region IV Only)
Comm. Remick GPA:CA Region V FD0
- 0lG Gen. Counsel
- ASLAP FAX TO:
HRR Research
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AE00 IRM
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g o g 32 910425 Rev. 10/23/90 l D PNO-II I-91-019 PDR
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