ENS 46453

v t e 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.

ENS 46453 +/-
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
v • d • e

v t e Emergency Notification System
Prostate Seed Center with Agreement State
WEEKMONTHYEAR2010-12-02T23:00:00 [Table view]
[ENS list for Prostate Seed Center]

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