Event Notification Report for September 26, 2001
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/25/2001 - 09/26/2001
EVENT NUMBERS
38320
Hospital
Event Number: 38320
Rep Org: QUEENS MEDICAL CENTER
Licensee: QUEENS MEDICAL CENTER
Region: 4
City: HONOLULU State: HI
County: HONOLULU
License #: 53-16533-02
Agreement: N
Docket:
NRC Notified By: SCOTT DUBE
HQ OPS Officer: STEVE SANDIN
Licensee: QUEENS MEDICAL CENTER
Region: 4
City: HONOLULU State: HI
County: HONOLULU
License #: 53-16533-02
Agreement: N
Docket:
NRC Notified By: SCOTT DUBE
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/26/2001
Notification Time: 22:07 [ET]
Event Date: 09/26/2001
Event Time: 09:00 [HST]
Last Update Date: 09/26/2001
Notification Time: 22:07 [ET]
Event Date: 09/26/2001
Event Time: 09:00 [HST]
Last Update Date: 09/26/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
GREG PICK (R4)
PATRICIA HOLAHAN (NMSS)
GREG PICK (R4)
PATRICIA HOLAHAN (NMSS)
MEDICAL MISADMINISTRATION INVOLVING DELIVERY OF TREATMENT TO THE WRONG SITE
At approximately 0900HST on 9/26, a patient undergoing treatment for restenosis of a cardiac vessel received a 23 gray dose using a Sr-90 source via intravascular brachytherapy. The error occurred due to difficulty in resolving the correct vessel segment location using fluoroscopy imaging. The attending radiologist and cardiologist reviewed film concluding that the wrong segment had been treated. The prescribed dose was then delivered to the correct site. The patient has not been informed and there are no adverse effects anticipated. The licensee will meet with the vendor to discuss appropriate corrective actions in use of the equipment.
At approximately 0900HST on 9/26, a patient undergoing treatment for restenosis of a cardiac vessel received a 23 gray dose using a Sr-90 source via intravascular brachytherapy. The error occurred due to difficulty in resolving the correct vessel segment location using fluoroscopy imaging. The attending radiologist and cardiologist reviewed film concluding that the wrong segment had been treated. The prescribed dose was then delivered to the correct site. The patient has not been informed and there are no adverse effects anticipated. The licensee will meet with the vendor to discuss appropriate corrective actions in use of the equipment.