Event Notification Report for January 24, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/23/2014 - 01/24/2014
Agreement State
Event Number: 49770
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: FLOWER HOSPITAL
Region: 3
City: SYLVANIA State: OH
County:
License #: 02120 49 0004
Agreement: Y
Docket:
NRC Notified By: KARL VON AHN
HQ OPS Officer: CHARLES TEAL
Licensee: FLOWER HOSPITAL
Region: 3
City: SYLVANIA State: OH
County:
License #: 02120 49 0004
Agreement: Y
Docket:
NRC Notified By: KARL VON AHN
HQ OPS Officer: CHARLES TEAL
Notification Date: 01/27/2014
Notification Time: 17:05 [ET]
Event Date: 01/24/2014
Event Time: 00:00 [EST]
Last Update Date: 01/27/2014
Notification Time: 17:05 [ET]
Event Date: 01/24/2014
Event Time: 00:00 [EST]
Last Update Date: 01/27/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
STUART SHELDON (R3DO)
FSME EVENT RESOURCE (EMAI)
STUART SHELDON (R3DO)
FSME EVENT RESOURCE (EMAI)
AGREEEMENT STATE REPORT - PATIENT RECEIVED LESS THAN PRESCRIBED DOSE
The following was received from the State of Ohio via email:
"On Jan. 27, 2014, the RSO of Flower Hospital provided a telephone report of medical event that occurred on Jan. 24 and 27, 2014.
"A patient was being treated with a Varian GammaMed Plus HDR with 4.7 Ci of lr-192 in a vaginal cylinder. The written directive was for three fractions of 500 cGy for a total of 1,500 cGy. Then during the delivery of the second fraction the licensee realized that they were only delivering a planned dose of 166 cGy. The licensee completed the second fraction as planned. The treatment planning was entered as one third of the 500 cGy for three fractions instead of three fractions of 500 cGy. The license will modify the treatment plan to give the full prescribed 1500 cGy to the patient.
"The patient was notified on Jan. 27, 2014.
"This is a reportable medical event under OAC 3701:1-58-101 (A)(1)(c.) for a fractionated dose that differs by more than 50%."
Ohio Report #: OH140001
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
The following was received from the State of Ohio via email:
"On Jan. 27, 2014, the RSO of Flower Hospital provided a telephone report of medical event that occurred on Jan. 24 and 27, 2014.
"A patient was being treated with a Varian GammaMed Plus HDR with 4.7 Ci of lr-192 in a vaginal cylinder. The written directive was for three fractions of 500 cGy for a total of 1,500 cGy. Then during the delivery of the second fraction the licensee realized that they were only delivering a planned dose of 166 cGy. The licensee completed the second fraction as planned. The treatment planning was entered as one third of the 500 cGy for three fractions instead of three fractions of 500 cGy. The license will modify the treatment plan to give the full prescribed 1500 cGy to the patient.
"The patient was notified on Jan. 27, 2014.
"This is a reportable medical event under OAC 3701:1-58-101 (A)(1)(c.) for a fractionated dose that differs by more than 50%."
Ohio Report #: OH140001
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
Agreement State
Event Number: 49764
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: BOSTON UNIVERSITY MEDICAL CENTER
Region: 1
City: BOSTON State: MA
County:
License #: 44-0062
Agreement: Y
Docket:
NRC Notified By: BRUCE PACKARD
HQ OPS Officer: HOWIE CROUCH
Licensee: BOSTON UNIVERSITY MEDICAL CENTER
Region: 1
City: BOSTON State: MA
County:
License #: 44-0062
Agreement: Y
Docket:
NRC Notified By: BRUCE PACKARD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/24/2014
Notification Time: 17:24 [ET]
Event Date: 01/24/2014
Event Time: 15:00 [EST]
Last Update Date: 01/24/2014
Notification Time: 17:24 [ET]
Event Date: 01/24/2014
Event Time: 15:00 [EST]
Last Update Date: 01/24/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)
MASSACHUSETTS AGREEMENT STATE REPORT - MISADMINISTRATION OF I-131
The following information was obtained from the Commonwealth of Massachusetts via facsimile:
"30 mCi of I-131 (NaI) was administered to the wrong patient. Blocking agent has been prescribed by doctor. Patient is described as in their 70s. Doctor and patient have been informed. 15 day report will follow."
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
The following information was obtained from the Commonwealth of Massachusetts via facsimile:
"30 mCi of I-131 (NaI) was administered to the wrong patient. Blocking agent has been prescribed by doctor. Patient is described as in their 70s. Doctor and patient have been informed. 15 day report will follow."
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
Agreement State
Event Number: 49815
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CLEVELAND CLINIC FOUNDATION
Region: 3
City: CLEVELAND State: OH
County:
License #: 02110180013
Agreement: Y
Docket:
NRC Notified By: KARL VON AHN
HQ OPS Officer: JEFF ROTTON
Licensee: CLEVELAND CLINIC FOUNDATION
Region: 3
City: CLEVELAND State: OH
County:
License #: 02110180013
Agreement: Y
Docket:
NRC Notified By: KARL VON AHN
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/11/2014
Notification Time: 17:37 [ET]
Event Date: 01/24/2014
Event Time: 00:00 [EST]
Last Update Date: 02/11/2014
Notification Time: 17:37 [ET]
Event Date: 01/24/2014
Event Time: 00:00 [EST]
Last Update Date: 02/11/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ROBERT DALEY (R3DO)
FSME EVENTS RESOURCE (EMAI)
ROBERT DALEY (R3DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING UNINTENDED DOSE
"During a liver radio embolization procedure with Y-90 SIRTEX Sir-Spheres on January 24, 2014 an unanticipated shunting occurred and was identified during the procedure. The procedure for the right liver lobe was stopped when the shunting was identified. The licensee runs contrast between vial doses to verify proper delivery of the microspheres. After imaging of the patient, the licensee determined on January 27, 2014 that the unintended dose to the gastric fundus was 11 Gray. The licensee reported the medical event to ODH BRP [Ohio Department of Health - Bureau of Radiation Protection] by telephone on February 11, 2014 at 3:30pm [EST].
"The referring physician and patient were notified on January 24, 2014. The patient is asymptomatic (no adverse effects) and is currently receiving medical monitoring."
Ohio Report #: OH140002
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
"During a liver radio embolization procedure with Y-90 SIRTEX Sir-Spheres on January 24, 2014 an unanticipated shunting occurred and was identified during the procedure. The procedure for the right liver lobe was stopped when the shunting was identified. The licensee runs contrast between vial doses to verify proper delivery of the microspheres. After imaging of the patient, the licensee determined on January 27, 2014 that the unintended dose to the gastric fundus was 11 Gray. The licensee reported the medical event to ODH BRP [Ohio Department of Health - Bureau of Radiation Protection] by telephone on February 11, 2014 at 3:30pm [EST].
"The referring physician and patient were notified on January 24, 2014. The patient is asymptomatic (no adverse effects) and is currently receiving medical monitoring."
Ohio Report #: OH140002
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.