ENS Event | |
|---|---|
23:00 Dec 2, 2010 | |
| Title | Agreement State Report - Delivered Dose Greater than Prescribed Dose |
| Event Description | The following information was received via email from the State of Colorado:
At approximately 1600 MST, 12/2/10, the Colorado Department of Public Health and Environment received a report of a possible misadministration at the Prostate Seed Center, a Colorado radioactive materials licensee. Additional information was received on 12/3/10 that there was indeed a misadministration of I-125 in seed form. An excess dose of 27 to 32% was administered above the prescribed dose. There was an apparent miscommunication between the supplier and the Prostate Seed Center about the units of dose the seeds were to contain. Apparently, Air Kerma units were ordered and milliCuries were delivered. An investigation as to the cause of the misadministration is being performed. A written report on the incident is required by the Department within 30 days. The excess dose was delivered to the patient's prostate. 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 | |
|---|---|
| Prostate Seed Center Littleton, Colorado (NRC Region 4) | |
| License number: | 972-01 |
| Organization: | Colorado Dept Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+16.65 h0.694 days <br />0.0991 weeks <br />0.0228 months <br />) | |
| Opened: | Edgar Ethington 15:39 Dec 3, 2010 |
| NRC Officer: | Eric Simpson |
| Last Updated: | Dec 3, 2010 |
| 46453 - NRC Website | |
Prostate Seed Center with Agreement State | |
WEEKMONTHYEARENS 464532010-12-02T23:00:0002 December 2010 23:00:00
[Table view]Agreement State Agreement State Report - Delivered Dose Greater than Prescribed Dose 2010-12-02T23:00:00 | |