ENS Event | |
|---|---|
04:00 Dec 10, 2008 | |
| Title | Agreement State Report - Unreported Medical Prostate Therapy Underdose Discovered During Audit |
| Event Description | The following information received via e-mail is historical and was discovered/reported to the State of Ohio on 05/04/2010:
NOTE: The information entered in this event notice was received from the licensee as a result of an audit ordered by the Ohio Department of Health for all brachytherapy procedures performed by the licensee since November 2004. This incident was referenced in Ohio NMED Item # OH100003. [See EN # 46272] On 12/10/08 the licensee performed a prostate seed implant with fifty-four (54) I-125 seeds prescribed to deliver a dose of 145 Gray [104.76 Gray actually delivered] to the prostate. During the procedure, six (6) seeds were 'stuck' in one needle, and inadvertently placed inferior to the prostate. The post implant dosimetry calculation performed on 2/12/09 showed a D90 of 72.25%, resulting in an underdose to the prostate greater than 20% of the prescribed dose. 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 | |
|---|---|
| Tiffin Mercy Hospital Tiffin, Ohio (NRC Region 3) | |
| License number: | 02120750001 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+15660.93 h652.539 days <br />93.22 weeks <br />21.452 months <br />) | |
| Opened: | Stephen James 15:56 Sep 23, 2010 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Sep 23, 2010 |
| 46273 - NRC Website | |
Tiffin Mercy Hospital with Agreement State | |
WEEKMONTHYEARENS 462732008-12-10T04:00:00010 December 2008 04:00:00
[Table view]Agreement State Agreement State Report - Unreported Medical Prostate Therapy Underdose Discovered During Audit 2008-12-10T04:00:00 | |