ENS Event | |
|---|---|
06:00 Feb 12, 2007 | |
| Title | Agreement State Report Involving Multiple Patients Receiving >20% Prescribed Dose |
| Event Description | The following information was received via email:
On Tuesday, February 13, 2007, the Agency [Texas Department of Health] was notified of a series of at least five medical events that were discovered when an improper dose rate constant was used in the treatment planning of the therapeutic application of permanent implants. The radioisotope is I-125 and it was used exclusively for the treatment of prostate cancer. The range of misadministrations is 21-36% over that which was prescribed in the written directive. The licensee is investigating the situation that involved some 28 patients treated over the past year but only one patient complication has been reported thus far. The Agency is continuing to investigate the events with the licensee and will provide updated information as it is received. Texas Incident No.: I-8391 A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. |
| Where | |
|---|---|
| Christus Santa Rosa Surgery Center - Llp San Antonio, Texas (NRC Region 4) | |
| License number: | L05805 |
| Organization: | Texas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+30.83 h1.285 days <br />0.184 weeks <br />0.0422 months <br />) | |
| Opened: | Ray Jisha 12:50 Feb 13, 2007 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Feb 13, 2007 |
| 43163 - NRC Website | |
Christus Santa Rosa Surgery Center - Llp with Agreement State | |
WEEKMONTHYEARENS 431632007-02-12T06:00:00012 February 2007 06:00:00
[Table view]Agreement State Agreement State Report Involving Multiple Patients Receiving >20% Prescribed Dose 2007-02-12T06:00:00 | |