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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 53539 | 2 August 2018 04:00:00 | Agreement State | Agreement State Report - Patient Overexposure | The following information was received via E-mail: The licensee reported to the (Ohio) Department (of Health) on 8/3/2018 that a potential medical event had occurred due to a delay in a surgical procedure. The delay was caused by the insurance company rescinding approval to remove a breast tumor until three medical opinions were obtained. The licensee implanted a 472 microCi I-125 seed (radioactive seed localization) (RSL) in the tumor on 5/29/2018 after receiving approval from the insurance company. The surgery was scheduled for 6/4/2018. The expected dose to the patient was 12.65 Rem to the tissue and 1.52 Rem EDE (Effective Dose Equivalent). The surgery was delayed until approval from the insurance company was obtained, and was performed on 8/2/2018. The delay resulted in a tissue dose of 99.45 Rem and EDE of 11.93 Rem. A follow-up will be conducted with the routine inspection in September. Ohio State Report: OH180006 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. |