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Start date | Reporting criterion | Title | Event description | System | LER | |
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ENS 47011 | 18 February 2008 05:00:00 | Agreement State | Agreement State Report - Medical Misadministration During Prostate Therapy | The state found three cases of prostate seed (Pd-103) medical misadministration during an inspection on 1/14/2011. These cases are related to one doctor. 2/18/2008: 100 Gy prescribed, 70.24 Gy administered 4/8/2008: 125 Gy prescribed, 71.6 Gy administered 3/17/2009: 100 Gy prescribed, 160.8 Gy administered The physician was notified of the misadministration however the patients were not notified. 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. |