ENS 42729

v t e 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.

ENS 42729 +/-
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
v • d • e

v t e Emergency Notification System
Akron General Medical Center with Agreement State
WEEKMONTHYEAR2017-11-06T05:00:00 [Table view]
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