ENS 46306

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v t e 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.

ENS 46306 +/-
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
v • d • e

v t e Emergency Notification System
Clinton Memorial Hospital with Agreement State
WEEKMONTHYEAR2008-02-06T04:00:00 [Table view]
[ENS list for Clinton Memorial Hospital]

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