Event Notification Report for May 13, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/12/2003 - 05/13/2003
Hospital
Event Number: 39845
Rep Org: UNIVERSITY WISCONSIN-MADISON
Licensee: UNIVERSITY WISCONSIN-MADISON
Region: 3
City: MADISON State: WI
County:
License #: 4809843-18
Agreement: N
Docket:
NRC Notified By: RONALD BRESELLS
HQ OPS Officer: RICH LAURA
Licensee: UNIVERSITY WISCONSIN-MADISON
Region: 3
City: MADISON State: WI
County:
License #: 4809843-18
Agreement: N
Docket:
NRC Notified By: RONALD BRESELLS
HQ OPS Officer: RICH LAURA
Notification Date: 05/14/2003
Notification Time: 12:35 [ET]
Event Date: 05/13/2003
Event Time: 14:00 [CDT]
Last Update Date: 05/14/2003
Notification Time: 12:35 [ET]
Event Date: 05/13/2003
Event Time: 14:00 [CDT]
Last Update Date: 05/14/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
SONIA BURGESS (R3)
JOHN HICKEY (NMSS)
SONIA BURGESS (R3)
JOHN HICKEY (NMSS)
MEDICAL EVENT AT UNIVERSITY WISCONSIN-MADISON
A significant under-exposure occurred on a patient undergoing therapy for liver cancer. The source was an SIR-SPHERE using .058 curies of Y-90 isotope. The Y-90 isotope was in semi-liquid form. The prescribed dose was 58 milli-curies and the patient was delivered only 2 milli-curies. The vendor of the machine has been contacted and will repair the equipment. The hospital speculated that the delivery tube may have had air leaks resulting in the source not being fully inserted. The patient has been rescheduled for the therapy on May 28, 2003.
A significant under-exposure occurred on a patient undergoing therapy for liver cancer. The source was an SIR-SPHERE using .058 curies of Y-90 isotope. The Y-90 isotope was in semi-liquid form. The prescribed dose was 58 milli-curies and the patient was delivered only 2 milli-curies. The vendor of the machine has been contacted and will repair the equipment. The hospital speculated that the delivery tube may have had air leaks resulting in the source not being fully inserted. The patient has been rescheduled for the therapy on May 28, 2003.
General Information or Other
Event Number: 39877
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY HOPSITALS OF CLEVELAND
Region: 3
City: Cleveland State: OH
County:
License #: OH-0211018007
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: JOHN MacKINNON
Licensee: UNIVERSITY HOPSITALS OF CLEVELAND
Region: 3
City: Cleveland State: OH
County:
License #: OH-0211018007
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: JOHN MacKINNON
Notification Date: 05/22/2003
Notification Time: 14:10 [ET]
Event Date: 05/13/2003
Event Time: 12:00 [EDT]
Last Update Date: 05/22/2003
Notification Time: 14:10 [ET]
Event Date: 05/13/2003
Event Time: 12:00 [EDT]
Last Update Date: 05/22/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ANNE MARIE STONE (R3)
DOUG BROADDUS (NMSS)
ANNE MARIE STONE (R3)
DOUG BROADDUS (NMSS)
RADIATION TREATMENT TO WRONG AREA
The Ohio Department of Health Bureau of Radiation Protection received a report of misadministration from University Hospitals of Cleveland on May 20, 2003. The report involved a Brachytherapy prostrate therapy with Iodine-125 seeds. The total amount of activity administered was 20.0 millicuries. Preliminary indication is a treatment to the wrong target area. A written report will be sent to the Ohio Department of Health within 15 days.
The Ohio Department of Health Bureau of Radiation Protection received a report of misadministration from University Hospitals of Cleveland on May 20, 2003. The report involved a Brachytherapy prostrate therapy with Iodine-125 seeds. The total amount of activity administered was 20.0 millicuries. Preliminary indication is a treatment to the wrong target area. A written report will be sent to the Ohio Department of Health within 15 days.