ENS Event | |
|---|---|
04:00 Jul 15, 2015 | |
| Title | Agreement State Report - Overdose to Patient During Prostate Seed Implant |
| Event Description | The following information was received via facsimile:
On July 16, 2015 the licensee informed the Department's [Pennsylvania Department of Environmental Protection Bureau of Radiation Protection] Central Office of a medical event. The event is reportable within 24-hours per 10 CFR 35.3045(a)(1)(i). Both the patient and referring physician were notified. On July 15, 2015, a patient was scheduled to receive a partial iodine-125 (I-125) prostate seed implant of 107 Gy, to be followed by a course of external beam radiation therapy of 45 Gy. During the procedure, the physician made an error and administered a full I-125 implant of 160 Gy. This resulted in a 49.5 percent overdose. No harm is expected to the patient. Cause of the event: Human error. The licensee plans to compensate for the overdose by eliminating the follow-up external beam therapy. A full report is expected within 15 days. The Southcentral Regional Office plans to perform a reactive inspection. More information will be provided as received. Pennsylvania Event Report ID No.: PA150020 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. |
| Where | |
|---|---|
| Reading Hospital West Reading, Pennsylvania (NRC Region 1) | |
| License number: | PA-0023 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+34.15 h1.423 days <br />0.203 weeks <br />0.0468 months <br />) | |
| Opened: | Joseph Melnic 14:09 Jul 16, 2015 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Jul 16, 2015 |
| 51237 - NRC Website | |
Reading Hospital with Agreement State | |
WEEKMONTHYEARENS 557662022-03-03T05:00:0003 March 2022 05:00:00
[Table view]Agreement State Agreement State - Underdose ENS 512372015-07-15T04:00:00015 July 2015 04:00:00 Agreement State Agreement State Report - Overdose to Patient During Prostate Seed Implant 2022-03-03T05:00:00 | |