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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 51565 | 24 July 2014 05:00:00 | Agreement State | Agreement State Report - Medical Underdose | The following report was received via e-mail: The licensee performed a prostate Iodine-125 (I-125) seed implant on July 24, 2014. The prescribed dose of 144 Gray (Gy) to 90 percent of the prostate gland (D90) was not within 20 percent of prescribed dose (144 Gy prescribed, 86.1 Gy administered). The post plan performed on August 12, 2014, demonstrated that the prostate D90 was 59.79 percent, not within 20 percent limit of the prescribed dose. The licensee did not notify the Ohio Department of Health of this occurrence as a medical event. The medical event was discovered as a result of an inspection conducted on 10/28/15. A Notice of Violation for the medical event and failure to report the medical event has been issued to the licensee. The investigation is ongoing. Ohio Report: OH150012 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. |