ENS Event | |
|---|---|
04:00 Jul 10, 2006 | |
| Title | Agreement State Report - Medical Overdose |
| Event Description | The following information was provided by the state related to prostate brachytherapy which was performed on 7/10/2006 using I-125 seeds.
Prostate seed implant plans are specified in kerma units (U) by default in our computer planning system. However, the ordering of seeds is specified in mCi [milliCuries]. In this instance the default seed strength was not changed to mCi and a plan was developed for [the patient] to receive 111 seeds of an activity of 0.394 U per seed when 0.394 mCi was desired. The order form was completed for 111 seeds of the expected (not planned) activity of 0.394 mCi per seed. The result was an implant with seeds of activity 27% higher than planned. The overdose was noticed by the hospital on 7/12/2006. The physician, the patient, and the State of Ohio were notified on 7/13/2006. The State inspected the facility on 7/18/2006. |
| Where | |
|---|---|
| Akron General Medical Center Akron, Ohio (NRC Region 3) | |
| License number: | 02120780000 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+390.8 h16.283 days <br />2.326 weeks <br />0.535 months <br />) | |
| Opened: | Mark Light 10:48 Jul 26, 2006 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Jul 26, 2006 |
| 42729 - NRC Website | |
Akron General Medical Center with Agreement State | |
WEEKMONTHYEARENS 530712017-11-06T05:00:0006 November 2017 05:00:00
[Table view]Agreement State Agreement State Report - Dose Greater than 50 Rem Delivered at a Site Not Intended for Treatment ENS 519802016-04-26T04:00:00026 April 2016 04:00:00 Agreement State Agreement State Report - Missing Source ENS 519792016-04-21T04:00:00021 April 2016 04:00:00 Agreement State Agreement State Report - Missing Source ENS 488392013-03-19T04:00:00019 March 2013 04:00:00 Agreement State Agreement State Report - Y-90 Sir-Sphere Under Dose of 87% ENS 486782013-01-15T05:00:00015 January 2013 05:00:00 Agreement State Agreement State Report - Misplacement of Brachytherapy Source During Medical Treatment ENS 431922006-09-27T05:00:00027 September 2006 05:00:00 Agreement State Agreement State Report - Potential Medical Event ENS 427292006-07-10T04:00:00010 July 2006 04:00:00 Agreement State Agreement State Report - Medical Overdose 2017-11-06T05:00:00 | |