ENS 47467

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v t e ENS Event
13:00 Nov 16, 2011
Title	Kentucky Agreement State Report - Wrong Brachytherapy Treatment Plan Performed on Wrong Patient
Event Description	The following information was obtained from the Commonwealth of Kentucky via email: Kentucky RHB [Radiation Health Branch] was notified via e-mail on 11/17/11 at 10:30 a.m. [EST] and via telephone call on 11/17/11 at 10:45 a.m. of a possible medical event occurring on 11/16/11. The medical event involved using the wrong permanent prostate brachytherapy implant treatment plan on the wrong patient. The facility performed back to back procedures on two patients on two consecutive days and the implant procedure used on the second patient was actually developed for the first patient. The RSO reported that immediately after completing the procedure, the mishap was noted by the Radiation Oncologist and a post implant CT and MRI were performed immediately. The Radiation Oncologist who developed the treatment plan and performed the procedure determined the dose delivered to the target organ based on D90 was 90%. According to the RSO, written directives for both patients called for the same number of seeds of the same radionuclide and same activity and both called for the same prescribed dose thus accounting for the oversight on the part of the Radiation Oncologist. These similarities however, allowed for a D90 of 90% despite the wrong treatment plan being used. The State will continue to keep NRC informed of the status of their investigation. The patient was given 79 seeds with 0.0406 mCi of I-125 per seed (STM 1251). The manufacturer was Bard Brachytherapy Inc. 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 47467 +/-
Where
The Medical Center At Bowling Green Bowling Green, Kentucky (NRC Region 1)
License number:	202-124-26
Organization:	Kentucky Dept Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+147.47 h6.145 days <br />0.878 weeks <br />0.202 months <br />)
Opened:	Curt Pendergrass 16:28 Nov 22, 2011
NRC Officer:	Howie Crouch
Last Updated:	Nov 22, 2011
47467 - NRC Website
v • d • e

v t e Emergency Notification System
The Medical Center At Bowling Green with Agreement State
WEEKMONTHYEAR2011-11-16T13:00:00 [Table view]
[ENS list for The Medical Center At Bowling Green]

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