ENS Event | |
|---|---|
19:00 Jun 12, 2006 | |
| Title | Medical Event - Higher Dose than Planned Administered During Brachytherapy Treatment |
| Event Description | A brachytherapy dose for prostate cancer treatment included a planned 145 Gy dose to be accomplished using permanently implanted I-125 seeds. A computer is used as part of the hospital's procedures for determining the quantity of seeds to implant to arrive at the total prescribed dose using the dose per seed. Hospital staff incorrectly entered the dose per seed as 0.27 millicuries instead of 0.34 millicuries into the computer. This resulted in the computer calculating a quantity of 100 seeds to be used and resulted in a 26% higher dose than intended. The error in the calculation was not discovered until after the actual implant was accomplished.
The medical consequences of the overdose include possible rectal complications in the future. Remedial actions could include removal of the prostate. The doctors are investigating other treatment options. The patient was being informed of the overdose and treatment options at the time of this report. |
| Where | |
|---|---|
| Bayhealth Medical Center Dover, Delaware (NRC Region 1) | |
| License number: | 07-14850-01 |
| Organization: | Bayhealth Medical Center |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+-1.67 h-0.0696 days <br />-0.00994 weeks <br />-0.00229 months <br />) | |
| Opened: | Raji Subramanyam 17:20 Jun 12, 2006 |
| NRC Officer: | Pete Snyder |
| Last Updated: | Jun 12, 2006 |
| 42634 - NRC Website | |
Bayhealth Medical Center with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 508042013-07-24T05:00:00024 July 2013 05:00:00
[Table view]10 CFR 35.3045(a)(1) Medical Misadministration During Iodine 125 Seed Implantation ENS 476232012-01-25T14:30:00025 January 2012 14:30:00 10 CFR 35.3045(a)(1) Misadministration of Thallium During Cardio Stress Test ENS 426342006-06-12T19:00:00012 June 2006 19:00:00 10 CFR 35.3045(a)(1) Medical Event - Higher Dose than Planned Administered During Brachytherapy Treatment 2013-07-24T05:00:00 | |