ENS 47069
ENS Event | |
|---|---|
17:00 Jul 15, 2011 | |
| Title | Agreement State Report - Delivered Dose Potentially Different than Prescribed Dose |
| Event Description | The following information was received by e-mail:
A routine inspection was performed of the licensee on July 11 and 12, 2011. Based on records reviewed at the time of inspection and additional documentation provided to the Kentucky Radiation Health Branch on July 15, 2011. Three unreported Medical Event(ME)s appeared to have occurred during the past three years. 1. On June 16, 2008 a Written Directive(WD) signed by an Authorized User [AU] for the administration for a total activity of 192.00 U (148.492 mCi) and a Prescription Dose of 125.0 Gy of Pd-103 seeds to the prostate. Manufacturer: Theragenics Model Number: Not Available Seed Lot No: NOT AVAILABLE Source Activity: 2.000 U (1.547 mCi )per seed Number of Seeds (Sources): 96 Based on the licensees use of the nationally recognized Report of AAPM [American Association of Physicists in Medicine] Task Group Report No. 64 for determining the dose received by the prostate a ME was identified. The post operative CT indicated the prostate received: D90 of 81.17 Gy (64.94%) of the prescribed dose. D100 of 43.71 Gy (34.97%) of the prescribed dose. 2. On March 23, 2009 a Written Directive(WD) signed by an Authorized User for the administration for a Total Activity of 133.560 U (103.295 mCi) and a Prescription dose of 90. Gy of PD-103 seeds to the prostate. Manufacturer: Theragenics Model Number: 200 Seed Lot No: 0910E Source Activity: 1.590 U (1.230 mCi) per seed Number of Seeds (Sources): 84 Based on the licensees use of the nationally recognized Report of AAPM Task Group Report No. 64 for determining the dose received by the prostate a ME was identified. The post operative CT indicated the prostate received: D90 of 55.41 Gy (61.57% ) of the prescribed dose. D100 of 28.03 Gy (31.15% of the prescribed dose). 3. On April 12, 2010 a Written Directive (WD) signed by an Authorized User for the administration for a Total Activity of 140.736 U (108.848 mCi) and a Prescription Dose of 125.0 Gy of PD-103 seeds to the prostate. Manufacturer: Theragenics Model Number: 200 Seed Lot No: 0910E Source Activity: 2.199 U (1.701 mCi ) per seed Number of Seeds (Sources): 64 Based on the licensees use of the nationally recognized Report of AAPM Task Group Report No. 64 for determining the dose received by the prostate a ME was identified. The post operative CT indicated the prostate received: D90 of 70.71 Gy (56.57% )of the prescribed dose. D100 of 34.21 Gy (27.36% of the prescribed dose). The licensee and the RSO [Radiation Safety Officer] were unaware the three procedures were reportable ME's. The RSO and the AU reviewed the Pre and Post implant plan and the AU was satisfied to follow the patients progress with repeated PSA testing. The licensee is currently reviewing the findings and implementing preventive measures agreed to by the licensee and the [Agreement State]. 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 | |
|---|---|
| Western Baptist Hospital Paducah, Kentucky (NRC Region 1) | |
| License number: | 20214226 |
| Organization: | Kentucky Dept Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+71.63 h2.985 days <br />0.426 weeks <br />0.0981 months <br />) | |
| Opened: | Michele Greenwell 16:38 Jul 18, 2011 |
| NRC Officer: | Vince Klco |
| Last Updated: | Jul 18, 2011 |
| 47069 - NRC Website | |
Western Baptist Hospital with Agreement State | |
WEEKMONTHYEARENS 470692011-07-15T17:00:00015 July 2011 17:00:00
[Table view]Agreement State Agreement State Report - Delivered Dose Potentially Different than Prescribed Dose 2011-07-15T17:00:00 | |