ENS 47980

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v t e ENS Event
05:00 Jun 4, 2009
Title	Agreement State Report - Three Medical Events Discovered During an Inspection
Event Description	The following report was received via e-mail: During a routine inspection, three unreported [prostate brachytherapy] medical events were identified. Case One: Implant Date: 6/4/2009 Prescribed dose: 145Gy to the prostate Post implant CT dosimetry: V100 (the volume of the prostate receiving 100% of the prescribed dose) totaled 69.71% Source: I-125 encapsulated seeds Vendor: IsoAid Model Number: IAI-125A Activity per seed: 0.330 mCi Number of seeds implanted: 69 Case Two: Implant Date: 6/19/2009 Prescribed dose: 145Gy to the prostate Post implant CT dosimetry: V100 (the volume of the prostate receiving 100% of the prescribed dose) totaled 62.77% Source: I-125 encapsulated seeds Vendor: IsoAid Model Number: IAI-125A Activity per seed: 0.330 mCi Number of seeds implanted: 80 Case Three: Implant Date: 10/29/2009 Prescribed dose: 145Gy to the prostate Post implant CT dosimetry: V100 (the volume of the prostate receiving 100% of the prescribed dose) totaled 65.34% Source: I-125 encapsulated seeds Vendor: IsoAid Model Number: IAI-125A Activity per seed: 0.330 mCi Number of seeds implanted: 84 * * UPDATE FROM CURT PENDERGRASS TO HOWIE CROUCH VIA EMAIL ON 6/5/12 AT 1018 EDT * * * D90 is defined as minimum dose received by 90% of CT-defined prostate volume Case 1 D90 = 72.80% of 145Gy Case 2 D90 = 58.86% of 145Gy Case 3 D90 = 54.00% of 145Gy Notified R1DO (Cahill) and FSME Events via email. 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 47980 +/-
Where
Owensboro Medical Health System Owensboro, Kentucky (NRC Region 1)
License number:	202-161-26
Organization:	Kentucky Dept Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+26218.33 h1,092.43 days <br />156.061 weeks <br />35.914 months <br />)
Opened:	Michele Greenwell 15:20 May 31, 2012
NRC Officer:	Mark Abramovitz
Last Updated:	Jun 5, 2012
47980 - NRC Website
v • d • e

v t e Emergency Notification System
Owensboro Medical Health System with Agreement State
WEEKMONTHYEAR2012-10-30T06:00:00 [Table view]
[ENS list for Owensboro Medical Health System]

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