ENS 40346

v t e ENS Event
22:00 Nov 20, 2003
Title	Total Dose Delivered Differs from Prescribed Dose by More than 20 Percent
Event Description	On 10/16/2003, patient underwent surgery to implant 89 I-125 seeds for treatment of prostate cancer. X-rays taken after surgery appeared to be normal. On 11/17/2003, a routine follow up CT scan was performed and the results were made available to Radiation Oncology on 11/20/2003. Review of the CT scan showed that approximately 80% of the implanted seeds were in adjacent tissue and not in the intended location. The original prescribed dose to the prostate was 145 Gray. The estimated dose to the prostate with the existing seed location is 18.6 Gray. On 11/21/2003, the medical center left multiple messages with the patient providing applicable contact numbers. The treating physician has been notified. The hospital will be conducting an investigation into the cause of the error and determining appropriate treatment for the patient.

ENS 40346 +/-
Where
Albert Einstein Medical Center Philadelphia, Pennsylvania (NRC Region 1)
License number:	37-00448-19
Organization:	Albert Einstein Medical Center
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+15.8 h0.658 days <br />0.094 weeks <br />0.0216 months <br />)
Opened:	Karen Colucci 13:48 Nov 21, 2003
NRC Officer:	Jeff Rotton
Last Updated:	Nov 21, 2003
40346 - NRC Website
v • d • e

v t e Emergency Notification System
Albert Einstein Medical Center with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2003-11-20T22:00:00 [Table view]
[ENS list for Albert Einstein Medical Center]

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