ENS Event | |
|---|---|
05:00 Jan 7, 2015 | |
| Title | Received Dose Differed from Prescribed Dose of I-125 |
| Event Description | On December 17, 2014, a patient had a 123 microCurie I-125 seed implanted in her breast as part of a treatment plan for non-palpable breast cancer. The treatment plan was to remove the seed after 5 days.
Due to illness, the patient was unable to return to the hospital to have the seed removed until January 7, 2015. This resulted in the patient receiving an 83.6 cGy exposure versus the prescribed 18.4 cGy exposure. The prescribing physician and the patient were notified. No permanent damage due to the exposure is expected. The licensee coordinated this report with NRC Region 1 Senior Health Physicist Penny Lanzisera. 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.
The licensee called to report two additional patients whose dose exceeded 50 cGy. The first patient was not medically cleared for the procedure. The patient received 57.9 cGy instead of the prescribed dose after 5 days of 21.8 cGy of I-125. The second patient refused to undergo the procedure until genetic testing was completed. The patient received 54 cGy instead of the prescribed dose after 5 days of 20.3 cGy of I-125. The licensee will modify their procedures to wait until patients are medically cleared and wait until all other testing is done prior to undergoing the procedure. Notified R1DO (DeFrancisco) and NMSS Events Notifications via email. |
| Where | |
|---|---|
| Danbury Hospital Danbury, Connecticut (NRC Region 1) | |
| License number: | 06-08544-01 |
| Organization: | Danbury Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+393.87 h16.411 days <br />2.344 weeks <br />0.54 months <br />) | |
| Opened: | Ruth Shanley 14:52 Jan 23, 2015 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Feb 3, 2015 |
| 50756 - NRC Website | |
Danbury Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 507562015-01-07T05:00:0007 January 2015 05:00:00
[Table view]10 CFR 35.3045(a)(1) Received Dose Differed from Prescribed Dose of I-125 2015-01-07T05:00:00 | |