ENS 53963

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v t e 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.

ENS 53963 +/-
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
v • d • e

v t e Emergency Notification System
Novant Health Presbyterian Medical Center with Agreement State
WEEKMONTHYEAR2019-03-05T04:00:00 [Table view]
[ENS list for Novant Health Presbyterian Medical Center]

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