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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 55852 | 18 April 2022 04:00:00 | Agreement State | Patient Underdose | The following was received from the Ohio Bureau of Radiation Protection by e-mail: On 4/18/22, a patient was scheduled to receive 120 Gy to the right hepatic lobe of the liver (involving Y-90 TheraSpheres), however only 94.2 Gy was delivered, resulting in an underdose of 21.5 percent. The (authorized user) notified the (Radiation Safety Officer) on 4/19/22. Stasis was not reached and at this time no cause was identified. Item Number: OH220006 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. | ||
| ENS 46333 | 6 April 2010 04:00:00 | Agreement State | Ohio Agreement State Report - D90 Dose Less than Prescribed Dose | The following information was obtained from the State of Ohio via email: Note: This information is reported as a result of a special inspection performed (by the State of Ohio) on July 28 and 29, 2010, limited to the licensee's prostate implant program. The licensee performed a prostate seed implant on April 6, 2010. The patient was prescribed a dose of 100 Gy using Iodine-125 seeds. The D90 post implant dosimetry performed on May 12, 2010, indicated a D90 of 62.5 Gy was given. This is a difference of 37.5% from the prescribed dose. The post plan dosimetry was performed by a radiation therapist on May 12, 2010, and the results were reviewed by a medical physicist on May 18, 2010. This qualifies as a Medical Event per rule 3701:1-58-101(A)(1)(a) of the Ohio Administrative Code (OAC). The licensee failed to notify by telephone the Ohio Department of Health no later than the next calendar day after the discovery of the medical event, and submit a written report within fifteen days after discovery of the medical (event). This is a violation of ODH requirements as referenced in rule 3701:1-58-101 (c) and (D). Ohio Report Number: OH100025 | ||
| ENS 41358 | 24 January 2005 05:00:00 | Agreement State | Agreement State Report of Administration of Radioactive Iodine to a Pregnant Patient | The following information is a preliminary report provided to the Ohio Department of Health Bureau of Radiation Protection concerning a patient at the Riverside Methodist Hospital in Columbus, Ohio that was administered radioactive iodine while pregnant. It has been brought to our attention that a patient that had been treated for hyperthyroidism at our facility was in fact pregnant at the time of the administration. The patient had an uptake study performed on 11/2/04 (205 microcuries of I-123 sodium iodine) pursuant to a diagnosis of hyperthyroidism. The patient was administered 12.7 millicuries of I-131 sodium iodine on 11/16/04 as treatment. The patient was counseled by the Authorized User prior to the administration and received written consent from the patient that she was not or could not be pregnant at that time. A pregnancy test was not performed to confirm or deny this fact. The fact that the patient was pregnant was brought to our attention when she saw her family practice physician (who was the referring physician for the uptake and hyperthyroidism treatment procedures) for complaints of abdominal pain. A radiograph of the abdomen was taken and the pregnancy discovered. This occurred sometime within the past week. The fact that the patient was pregnant was relayed to the Authorized User, who, in conjunction with the referring physician, referred the patient to a prenatal specialist to determine the age of the fetus. The specialist determined the delivery date to be 4/25/05, which meant the age of the fetus at the time of the I-131 administration was 17 weeks. This determination was made on January 24, 2005, and the RSO's staff called the (Ohio Department of Health) to report the event after gathering information for a dosimetry study at approximately 10 AM, 25 January, 2005. The dosimetry estimate for the fetus was approximately 2.0432 rad to the whole fetus and 22,400 rad to the fetal thyroid from both the I-123 and I-131 administrations. It should be noted that the patient underwent a CT angiogram on 9/24/04 (fetal age 8 weeks), but that this dose and the abdominal x-ray taken last week were not added to the fetal whole body dose since specific technique factors were not available for these studies which were performed elsewhere. The patient will be notified of the treatment plan for the continuation of the pregnancy today or tomorrow, once the prenatal specialist receives the dosimetry estimate the RSO provided the Authorized User. The referring physician has been in close contact with the Authorized User throughout this process. The Ohio Department of Health considers this an "Abnormal Occurrence" and will be conducting an investigation commencing this Friday (1/28/05). Ohio Dept of Health Report # 2005-001 |