ENS 51237

v t e ENS Event
04:00 Jul 15, 2015
Title	Agreement State Report - Overdose to Patient During Prostate Seed Implant
Event Description	The following information was received via facsimile: On July 16, 2015 the licensee informed the Department's [Pennsylvania Department of Environmental Protection Bureau of Radiation Protection] Central Office of a medical event. The event is reportable within 24-hours per 10 CFR 35.3045(a)(1)(i). Both the patient and referring physician were notified. On July 15, 2015, a patient was scheduled to receive a partial iodine-125 (I-125) prostate seed implant of 107 Gy, to be followed by a course of external beam radiation therapy of 45 Gy. During the procedure, the physician made an error and administered a full I-125 implant of 160 Gy. This resulted in a 49.5 percent overdose. No harm is expected to the patient. Cause of the event: Human error. The licensee plans to compensate for the overdose by eliminating the follow-up external beam therapy. A full report is expected within 15 days. The Southcentral Regional Office plans to perform a reactive inspection. More information will be provided as received. Pennsylvania Event Report ID No.: PA150020 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 51237 +/-
Where
Reading Hospital West Reading, Pennsylvania (NRC Region 1)
License number:	PA-0023
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+34.15 h1.423 days <br />0.203 weeks <br />0.0468 months <br />)
Opened:	Joseph Melnic 14:09 Jul 16, 2015
NRC Officer:	Donald Norwood
Last Updated:	Jul 16, 2015
51237 - NRC Website
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v t e Emergency Notification System
Reading Hospital with Agreement State
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