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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 46366 | 26 October 2010 04:00:00 | 10 CFR 35.3045(a)(1) | Two Medical Events Involving Received Dose Less than Prescribed Dose | During an on-site NRC Inspection on 10/26/10, two (2) medical events were identified both involving a delivered dose less than the prescribed dose following implant of Palladium-103 seed for prostate therapy. Specific details as follows: First Medical Event Preplanning date: 08/26/09 Post planning date: 09/03/09 D-90 (dose received by 90% of the prostate volume): 72% Underdose: 28% Prescribed: Palladium-103, 156U consisting of 65 seeds, 2.4U/seed Second Medical Event Preplanning date: 12/08/09 Post planning date: 12/29/09 D-90 (dose received by 90% of the prostate volume): 64% Underdose: 36% Prescribed: Palladium-103, 173U consisting of 74 seeds, 2.4U/seed Both underdoses are attributed to prostate swelling. The physician reviewing the results concluded that there was no adverse impact on either patient. The licensee will continue reviewing medical records to identify any additional occurrences of this nature. 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.
Based on a post evaluation by the licensee's Radiation Safety Officer and physicians, all delivered dose came within 20% of overall prescribed dose. Thus, this is not considered a medical event. Notified the R3DO (Stone), and FSME (McIntosh). | ||
| ENS 46319 | 6 October 2010 04:00:00 | 10 CFR 35.3045(a)(1) | Delivered Dose Potentially Different than the Prescribed Dose | During a brachytherapy treatment, the patient breast received an incorrect entry of the catheter position from a treatment planning system. Because of this, the prescribed dose was 340 centi-Gray at 1 centimeter from the tumor cavity while the actual dose received was 680 centi-Gray at 1 centimeter from the tumor cavity. The physician notified the patient of the potential dose difference. Based on physician review, it was determined that there was no affect on the patient. The reason for the potential dose difference was due to a missed change of a program default in the software program of the radiation treatment planning system. A new check step has been added to the Community Hospital procedure in order to correct the issue.
The licensee is updating this report to confirm that upon further evaluation this is a medical event. Notified R3DO (Skokowski) and FSME (Burgess). 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 46381 | 28 May 2008 04:00:00 | 10 CFR 35.3045(a)(1) | Two Medical Events Involving Received Dose Less than Prescribed Dose | During an on-site NRC Inspection two (2) medical events were identified both involving a delivered dose less than the prescribed dose following implant of Palladium-103 seed for prostate therapy. Specific details as follows: First Medical Event Preplanning date: 5/18/08 Post planning date: 5/18/08 Dose received by prostate volume: 44% Underdose: 56% Prescribed: Palladium-103, 140.42U consisting of 59 seeds, 2.38U/seed Second Medical Event Preplanning date: 7/8/08 Post planning date: 7/8/08 Dose received by prostate volume: 44% Underdose: 56% Prescribed: Palladium-103, 196.80U consisting of 82 seeds, 2.38U/seed Both underdoses are attributed to prostate swelling. The physician reviewing the results concluded that there was no adverse impact on either patient. The licensee will continue reviewing medical records to identify any additional occurrences of this nature. 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.
Based on a post evaluation by the licensee's Radiation Safety Officer and physicians, all delivered dose came within 20% of overall prescribed dose. Thus, this is not considered a medical event. Notified the R3DO (Stone), and FSME (McIntosh). |