ENS 45308

v t e ENS Event
22:00 Aug 27, 2009
Title	Medical Event - Patient Received 60% Less Dose than Prescribed
Event Description	The licensee was performing reviews on past procedures when they discovered the following reportable event: On March 3, 2009, a patient received a permanent prostate implant with a prescribed D90 dose of 144 Gy. The implant used fifty-eight I-125 seeds. On April 3, 2009, the patient returned to the facility for a post-implant CT/dose reconstruction and it was determined that the D90 dose received by the patient was 85 Gy which is 60% of the prescribed dose. The patient and prescribing physician were notified and the patient underwent an external radiation treatment to compensate. 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.

ENS 45308 +/-
Where
Karmanos Cancer Center Detroit, Michigan (NRC Region 3)
License number:	21-04127-06
Organization:	Karmanos Cancer Center
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+19.08 h0.795 days <br />0.114 weeks <br />0.0261 months <br />)
Opened:	Joe Rakowski 17:05 Aug 28, 2009
NRC Officer:	Howie Crouch
Last Updated:	Aug 28, 2009
45308 - NRC Website
v • d • e

v t e Emergency Notification System
Karmanos Cancer Center with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2009-08-27T22:00:00 [Table view]
[ENS list for Karmanos Cancer Center]

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