The following report was received from the
North Carolina Division of Health Service Regulation via email:
The facility had two I-125 prostate implant procedures scheduled for 5/26/2021, one from approximately 0800-1030 EDT and another one following that. During the preparation of the second patient, the [authorized medical physicist/ radiation safety officer] (AMP/RSO) realized he may have made a mistake inputting the source strength into the treatment planning computer. The treatment planning computer has two options for source strength (millicuries and air-kerma). He went back to verify and realized he had input the millicurie source strength (0.357 mCi) into the air-kerma strength (0.453 U) spot and not air-kerma. This resulted in the treatment planning computer to believe the activity of the sources were lower than they actually were and generated a plan off of this strength. This caused the delivered dosage to be 27 percent greater than the prescribed dosage (~1400 Gy not 1100 Gy). The referring physician was present for the procedure and was notified upon the realization of the error. The patient was still in recovery from the procedure and was informed by the authorized user as soon as he was recovered and able to receive the news, before leaving the facility. The AMP/RSO stated that no negative outcome was expected for the patient, as this was the first part of a two part treatment plan, with the second part being linear accelerator treatment on the prostate. The second part of the treatment can be adjusted to accommodate for the increased dose given during the permanent implant, with no expected harm to the patient.
NC Tracking Number: NC210008
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.
- * * UPDATE FROM TRAVIS CARTOSKI TO DONALD NORWOOD AT 1512 EDT ON 6/9/2021 * * *
The following information was received via E-mail from the North Carolina Division of Health Service Regulation:
Corrective Actions: Procedure Revision.
The North Carolina Division of Health Service Regulation has completed their investigation and considers the event closed.
Notified R1DO (Ferdas) and the
NMSS Events Notification E-mail group.