ENS 46273

v t e 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. Ohio NMED Item # OH100019. 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 46273 +/-
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
v • d • e

v t e Emergency Notification System
Tiffin Mercy Hospital with Agreement State
WEEKMONTHYEAR2008-12-10T04:00:00 [Table view]
[ENS list for Tiffin Mercy Hospital]

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