ENS 50135

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v t e ENS Event
05:00 May 22, 2014
Title	Agreement State Report - Patient Overexposure Due to Miscalculation
Event Description	The following was received from the State of Nebraska via fax: At 1430 CDT, the RSO from Nebraska Methodist Hospital called to report a possible overexposure to a patient who had received a prostate treatment of implanted lodine-125 seeds. The RSO, who was also the Medical Physicist on the case, stated that he had mistakenly used the millicurie value for the air kerma value. The treatment dose was intended to be 145 Gray (14,500 rad) but the implant dose was calculated to be 178 Gray (17,800 rad) so the dose differentiated by 27 percent. It is unknown if the target organ (rectum) will exceed 50 rem. Nebraska Item Number: NE140004 * * UPDATE FROM TRUDY HILL TO CHARLES TEAL AT 1659 EDT ON 6/16/14 * * * The following was received from the State of Nebraska via email: In a letter dated June 3, 2014, the RSO/Medical Physicist from Nebraska Methodist Hospital updated the information for this incident. The implanted dose was 184 Gray. The dose to the organ at risk (rectum) is as follows: Only a small percentage of the entire organ (rectum) was imaged and contoured, in the plan that was 12cc. An estimate of the increased dose ranges from 16 Gray in the highest dose regions comprising 90% of the contoured volume and 27 Gray in the highest dose regions comprising 30% of the contoured volume. The patient was informed within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of the discovery of the misadministration. Notified R4DO (Hay) and FSME Event Resource 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 50135 +/-
Where
Nebraska Methodist Hospital Lincoln, Nebraska (NRC Region 4)
License number:	01-07-02
Organization:	Ne Div Of Radioactive Materials
Reporting

Agreement State
Time - Person (Reporting Time:+35.08 h1.462 days <br />0.209 weeks <br />0.0481 months <br />)
Opened:	Howard Shuman 16:05 May 23, 2014
NRC Officer:	Daniel Mills
Last Updated:	Jun 16, 2014
50135 - NRC Website
v • d • e

v t e Emergency Notification System
Nebraska Methodist Hospital with Agreement State
WEEKMONTHYEAR2014-05-22T05:00:00 [Table view]
[ENS list for Nebraska Methodist Hospital]

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ENS Notification