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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 53086 | 20 November 2017 05:00:00 | Agreement State | Agreement State Report - Potential Medical Underdose | The following information was received via e-mail: ODH (Ohio Department of Health) was notified of a potential medical event by Fairview Hospital. The licensee performed a permanent prostate seed implant using I-125 according to the treatment plan. When the post implant dosimetry was performed, the D90 coverage was calculated to be 73% of the prescribed dose. After an initial investigation by the licensee, it was determined the under dose was caused by an 18% increase in prostate size compared to the pre-plan, which was prescribed 6 weeks prior to treatment. At the time of reporting, the licensee had informed the referring physician but they did not inform the patient. The licensee believes that once the inflammation subsides the D90 coverage will be within the prescribe treatment plan. NMED will be updated once ODH receives additional information from the licensee and conducts an investigation of the event. Ohio Event: OH170009 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. |