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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 47121 | 8 June 2011 04:00:00 | Agreement State | Agreement State Report Involving an Under-Dose | The following report was received from the State of Virginia via fax: On June 8, 2011, a prostate implant procedure was performed utilizing 57 seeds of 0.406 mCi/seed to a gland size of 33.7 cc. The intended dose was 145 Gy. On August 2nd during a post-plan evaluation, a CT was performed where it was discovered the base of the prostate was under-dosed. It is estimated that all 57 seeds are 1 cm short of the far superior position. The prescribed minimum D-90 dose was 80 Gy, a calculation was performed estimating that the actual dose delivered was 51 Gy. The physician and patient have been notified. A follow-up visit has been scheduled. Virginia Event Report ID No.: VA-11-06 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. |