ENS 42388: Difference between revisions
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| facility = Via Christi Cancer Center | | facility = Via Christi Cancer Center | ||
| Organization = Ok Deq Rad Management | | Organization = Ok Deq Rad Management | ||
| license number = | | license number = OK-14046-02 | ||
| region = 4 | | region = 4 | ||
| state = Oklahoma | | state = Oklahoma | ||
| Line 16: | Line 16: | ||
| event date = 03/01/2006 12:00 CST | | event date = 03/01/2006 12:00 CST | ||
| last update date = 03/06/2006 | | last update date = 03/06/2006 | ||
| title = Incorrect Dose Given | | title = Incorrect Dose Given to Prostate Patient | ||
| event text = The State provided the following information via facsimile: | | event text = 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. | 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. | ||
Latest revision as of 19:35, 24 November 2018
| Where | |
|---|---|
| Via Christi Cancer Center Ponca City, Oklahoma (NRC Region 4) | |
| License number: | OK-14046-02 |
| Organization: | Ok Deq Rad Management |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+112.5 h4.688 days <br />0.67 weeks <br />0.154 months <br />) | |
| Opened: | M. Broderick 10:30 Mar 6, 2006 |
| NRC Officer: | John Mackinnon |
| Last Updated: | Mar 6, 2006 |
| 42388 - NRC Website | |