ENS Event | |
|---|---|
19:40 Feb 17, 2005 | |
| Title | Medical Event - Total Dose Delivered Differs from Prescribed Dose |
| Event Description | Licensee called to report that on 02/16/05, the hospital performed a prostate seed implant. It was discovered after the implants were performed that the activity content for the first set of seeds (63 seeds) was incorrect. The hospital had ordered 0.27 millicuries per seed of I-125 and received 0.37 millicuries per seed. The order had been placed and confirmed with the seed manufacturing company, but the incorrect activity per seed was sent for the first of three implants for this patient. The documentation that was supplied with the order did identify the first set of seeds containing 0.37 millicuries per seed. Both the patient and the referring physician have been notified of the error. A post implant CT was performed to attempt to accurately calculate the dose overage, but the licensee determined that process would be difficult to verify. Licensee is evaluating methods to prevent reoccurrence (such as - perform own source calibration, verify documentation prior to implantation). Licensee did state that there was no unintended permanent functional damage to an organ or physiological system. |
| Where | |
|---|---|
| Porter Memorial Hospital Valparaiso, Indiana (NRC Region 3) | |
| License number: | 13-170-73-01 |
| Organization: | Porter Memorial Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+-4.87 h-0.203 days <br />-0.029 weeks <br />-0.00667 months <br />) | |
| Opened: | Appareo Devata 14:48 Feb 17, 2005 |
| NRC Officer: | Jeff Rotton |
| Last Updated: | Feb 17, 2005 |
| 41416 - NRC Website | |
Porter Memorial Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 414162005-02-17T19:40:00017 February 2005 19:40:00
[Table view]10 CFR 35.3045(a)(1) Medical Event - Total Dose Delivered Differs from Prescribed Dose 2005-02-17T19:40:00 | |