ENS 46333

v t e ENS Event
04:00 Apr 6, 2010
Title	Ohio Agreement State Report - D90 Dose Less than Prescribed Dose
Event Description	The following information was obtained from the State of Ohio via email: Note: This information is reported as a result of a special inspection performed [by the State of Ohio] on July 28 and 29, 2010, limited to the licensee's prostate implant program. The licensee performed a prostate seed implant on April 6, 2010. The patient was prescribed a dose of 100 Gy using Iodine-125 seeds. The D90 post implant dosimetry performed on May 12, 2010, indicated a D90 of 62.5 Gy was given. This is a difference of 37.5% from the prescribed dose. The post plan dosimetry was performed by a radiation therapist on May 12, 2010, and the results were reviewed by a medical physicist on May 18, 2010. This qualifies as a Medical Event per rule 3701:1-58-101(A)(1)(a) of the Ohio Administrative Code (OAC). The licensee failed to notify by telephone the Ohio Department of Health no later than the next calendar day after the discovery of the medical event, and submit a written report within fifteen days after discovery of the medical [event]. This is a violation of ODH requirements as referenced in rule 3701:1-58-101 (c) and (D). Ohio Report Number: OH100025

ENS 46333 +/-
Where
Riverside Methodist Hospital Columbus, Ohio (NRC Region 3)
License number:	02120250070
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+4593.72 h191.405 days <br />27.344 weeks <br />6.292 months <br />)
Opened:	Stephen James 13:43 Oct 14, 2010
NRC Officer:	Howie Crouch
Last Updated:	Oct 14, 2010
46333 - NRC Website
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