ENS Event | |
|---|---|
08:00 Nov 17, 2017 | |
| Title | Agreement State Report - Medical Underdose |
| Event Description | Eye plaque brachytherapy was being performed using I-125 seeds with a prescribed dose of 85 Gray. After the dose, the Iso-dose curve was noted to be different from the brachytherapy plan i.e. the dose was deeper than expected. Investigation revealed that a new model plaque was used which differed from the previous model. This resulted in an underdose with 65 Gray actually administered.
Oregon Report: 17-0073 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. |
| Where | |
|---|---|
| Oregon Health And Science University Portland, Oregon (NRC Region 4) | |
| License number: | ORE-90013 |
| Organization: | Or Dept Of Health Rad Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+127.37 h5.307 days <br />0.758 weeks <br />0.174 months <br />) | |
| Opened: | Daryl Leon 15:22 Nov 22, 2017 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Nov 22, 2017 |
| 53088 - NRC Website | |
Oregon Health And Science University with Agreement State | |
WEEKMONTHYEARENS 554242021-08-21T20:00:00021 August 2021 20:00:00
[Table view]Agreement State Prescribed Dose Exceeded ENS 530882017-11-17T08:00:00017 November 2017 08:00:00 Agreement State Agreement State Report - Medical Underdose ENS 509912015-04-15T07:00:00015 April 2015 07:00:00 Agreement State Agreement State Report - Source Moved During Medical Treatment ENS 505542014-10-17T07:00:00017 October 2014 07:00:00 Agreement State Agreement State Report - Medical Misadministration 2021-08-21T20:00:00 | |