ENS Event | |
|---|---|
04:00 Feb 6, 2008 | |
| Title | Agreement State Report - Medical Underdose During Prostate Brachytherapy |
| Event Description | The following report was received via e-mail:
The following report details "three Ohio Event Reports for two unreported medical events in 2008 (OH100022 and OH100023) and one unreported medical event in 2009 (OH100024). These events were discovered as a result of a special inspection conducted by ODH on 9/10/2010. Ohio Report Number OH100022: "An unreported medical event occurred at Clinton Memorial Hospital in Wilmington, Ohio on 2/6/08. On that date the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 144 Gray to the prostate. Post implant dosimetry showed that the received dose was >20 % below the prescribed dose." [The actual dose delivered was 97.5 Gray] Ohio Report Number OH100023: "An unreported medical event occurred at Clinton Memorial Hospital in Wilmington, Ohio on 3/21/08. On that date the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 145 Gray to the prostate. Post implant dosimetry showed that the received dose was >20 % below the prescribed dose." [The actual dose delivered was 102.5 Gray] Ohio Report Number OH100024: "An unreported medical event occurred at Clinton Memorial Hospital in Wilmington, Ohio on 5/20/09. On that date the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 144 Gray to the prostate. Post implant dosimetry showed that the received dose was >20 % below the prescribed dose." [The actual dose delivered was 107.5 Gray] 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 | |
|---|---|
| Clinton Memorial Hospital Wilmington, Ohio (NRC Region 3) | |
| License number: | 02120140000 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+23315.98 h971.499 days <br />138.786 weeks <br />31.938 months <br />) | |
| Opened: | Stephen James 14:59 Oct 4, 2010 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Oct 4, 2010 |
| 46306 - NRC Website | |
Clinton Memorial Hospital with Agreement State | |
WEEKMONTHYEARENS 463062008-02-06T04:00:0006 February 2008 04:00:00
[Table view]Agreement State Agreement State Report - Medical Underdose During Prostate Brachytherapy ENS 430912006-12-01T05:00:0001 December 2006 05:00:00 Agreement State Agreement State - Ohio - Equipment Malfunction of a Cobalt Teletherapy Device 2008-02-06T04:00:00 | |