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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 46273 | 10 December 2008 04:00:00 | Agreement State | Agreement State Report - Unreported Medical Prostate Therapy Underdose Discovered During Audit | The following information received via e-mail is historical and was discovered/reported to the State of Ohio on 05/04/2010: NOTE: The information entered in this event notice was received from the licensee as a result of an audit ordered by the Ohio Department of Health for all brachytherapy procedures performed by the licensee since November 2004. This incident was referenced in Ohio NMED Item # OH100003. (See EN # 46272) On 12/10/08 the licensee performed a prostate seed implant with fifty-four (54) I-125 seeds prescribed to deliver a dose of 145 Gray (104.76 Gray actually delivered) to the prostate. During the procedure, six (6) seeds were 'stuck' in one needle, and inadvertently placed inferior to the prostate. The post implant dosimetry calculation performed on 2/12/09 showed a D90 of 72.25%, resulting in an underdose to the prostate greater than 20% of the prescribed dose. Ohio NMED Item # OH100019. 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. |