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Start date | Reporting criterion | Title | Event description | System | LER | |
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ENS 50267 | 13 November 2013 04:00:00 | Agreement State | Agreement State Report - Brachytherapy Underdose | The following information was received via fax: This medical event (ME) was self-identified by the licensee during an audit. A patient who had undergone an iodine-125 (I-125) prostate brachytherapy procedure was reported to have a 'D90' dose of 43% of the written directive. The licensee radiation safety officer and physician are in contact regarding this ME. It is unknown at this time if the patient has been notified. The Department (Pennsylvania Department of Environmental Protection) is waiting for the required 15 day written report from the licensee. The Department will then conduct a reactive inspection. PA Event Number: PA140017 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.
The following information was received via facsimile: Through an internal audit, it was initially thought that a patient who had undergone an iodine-125 (I-125) prostrate brachytherapy treatment in November, 2013 was believed to have had a 'D90' dose of only 43% of the written directive. However, based on a re-assessment by the licensee's Chief Medical Physicist, it appears that greater than 80% of the prostate volume received the prescribed dose. (The) reported medical event is to be retracted. Notified R1DO (Dimitriadis) and FSME Events Resource via E-mail. |