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 Start dateReporting criterionTitleEvent descriptionSystemLER
ENS 5438330 October 2019 05:00:00Agreement StateAgreement State Report - Underdose by 20 Percent or MoreThe following was received from the Ohio Department of Heath via email: On 11/30/2019, the licensee notified the Ohio Department of Heath of a medical event involving a prostate seed implant. The licensee stated that it appears the implant template shifted prior to seed placement and resulted in a 48 percent underdose. The patient and referring physician have been notified. Isotope: Cs-131, 104.377 MBq Intended dose: 11000 rad Given dose: 6820 rad Item Number: OH190015 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.