ENS 47121

v t e ENS Event
04:00 Jun 8, 2011
Title	Agreement State Report Involving an Under-Dose
Event Description	The following report was received from the State of Virginia via fax: On June 8, 2011, a prostate implant procedure was performed utilizing 57 seeds of 0.406 mCi/seed to a gland size of 33.7 cc. The intended dose was 145 Gy. On August 2nd during a post-plan evaluation, a CT was performed where it was discovered the base of the prostate was under-dosed. It is estimated that all 57 seeds are 1 cm short of the far superior position. The prescribed minimum D-90 dose was 80 Gy, a calculation was performed estimating that the actual dose delivered was 51 Gy. The physician and patient have been notified. A follow-up visit has been scheduled. Virginia Event Report ID No.: VA-11-06 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 47121 +/-
Where
Lewis Gale Medical Center Salem, Virginia (NRC Region 1)
License number:	VA-161-126-1
Organization:	Virginia Rad Materials Program
Reporting

Agreement State
Time - Person (Reporting Time:+1354.73 h56.447 days <br />8.064 weeks <br />1.856 months <br />)
Opened:	Michael Welling 14:44 Aug 3, 2011
NRC Officer:	Steve Sandin
Last Updated:	Aug 3, 2011
47121 - NRC Website
v • d • e

v t e Emergency Notification System
Lewis Gale Medical Center with Agreement State
WEEKMONTHYEAR2011-06-08T04:00:00 [Table view]
[ENS list for Lewis Gale Medical Center]

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