ENS 42634

v t e 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.

ENS 42634 +/-
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
v • d • e

v t e Emergency Notification System
Bayhealth Medical Center with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2013-07-24T05:00:00 [Table view]
[ENS list for Bayhealth Medical Center]

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