Semantic search
Jump to navigation
Jump to search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 42388 | 1 March 2006 18:00:00 | Agreement State | Incorrect Dose Given to Prostate Patient | The State provided the following information via facsimile: The medical physicist for the Via Christi Cancer Center reported that a medical event had occurred the day before. A patient was treated for prostate cancer with I-125 seeds. An activity of 0.4 air kerma units per seed was ordered. The seeds were received with an activity of 0.4 millicuries per seed. The difference in activity units was not detected until after the surgery was completed. The patient received a total dose of 12,850 centigray rather than the prescribed 10,000 centigray; a 28% difference. The radiation oncologist has determined that this larger dose should not cause any untoward harm to the patient. The referring urologist and the patient have been notified of the dose discrepancy. As corrective action, the licensee plans to introduce a new form to be used as part of the procedure followed during permanent implant preparation. This form will be used to record seed activity, including the units, used in treatment planning, listed on the shipping form as well as the seed activity observed at the time of implant. OK Item # - OK060004 |