ENS Event | |
|---|---|
04:00 Mar 5, 2019 | |
| Title | Agreement State Report - Incorrect Source Strength Entered Resulting in Overdose of 20 Percent |
| Event Description | The following report was received from the North Carolina Division of Health Service Regulation via email:
A prostate patient returned for a 30 day post treatment review and CT scan. Licensee Physics Group reviewed the Post Op Plan with the Intended Plan. It was found that when the Intended Plan was entered into the planning software, a dosimetrist entered an incorrect source strength into the planning system, causing the planning system to appear to be implanting weaker seeds than were being implanted resulting in an over dose of 20 percent. Event Date: 3/5/19 Discovered Date: 3/28/1 Prescribed dose: 164.85 mCi Administered dose: 213.15 mCi Isotope: PD-103. Target organ: Prostate Referring Physician notified on: 3/28/19 Patient notified on: 3/28/19 Effects/Outcome to the Patient: None anticipated. Physician will monitor patient for side effects. Notifications & Generic Implications: None. Corrective Action: Procedure revision. A reactive inspection was conducted today [by the North Carolina Division of Health Service Regulation]. Following this entry into NMED we [the North Carolina Division of Health Service Regulation] would like to request the event be closed and complete. We [the North Carolina Division of Health Service Regulation] have concluded our investigation. NC Tracking Number: 190011 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 | |
|---|---|
| Novant Health Presbyterian Medical Center Charlotte, North Carolina (NRC Region 1) | |
| License number: | 060-0019-1 |
| Organization: | Nc Div Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+584.02 h24.334 days <br />3.476 weeks <br />0.8 months <br />) | |
| Opened: | Travis Cartoski 11:01 Mar 29, 2019 |
| NRC Officer: | Jeff Herrera |
| Last Updated: | Mar 29, 2019 |
| 53963 - NRC Website | |
Novant Health Presbyterian Medical Center with Agreement State | |
WEEKMONTHYEARENS 539632019-03-05T04:00:0005 March 2019 04:00:00
[Table view]Agreement State Agreement State Report - Incorrect Source Strength Entered Resulting in Overdose of 20 Percent 2019-03-05T04:00:00 | |