ENS Event | |
|---|---|
04:00 Jun 8, 2011 | |
| Title | Agreement State Report Involving an Under-Dose |
| Event Description | The following report was received from the State of Virginia via fax:
On June 8, 2011, a prostate implant procedure was performed utilizing 57 seeds of 0.406 mCi/seed to a gland size of 33.7 cc. The intended dose was 145 Gy. On August 2nd during a post-plan evaluation, a CT was performed where it was discovered the base of the prostate was under-dosed. It is estimated that all 57 seeds are 1 cm short of the far superior position. The prescribed minimum D-90 dose was 80 Gy, a calculation was performed estimating that the actual dose delivered was 51 Gy. The physician and patient have been notified. A follow-up visit has been scheduled. Virginia Event Report ID No.: VA-11-06 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 | |
|---|---|
| Lewis Gale Medical Center Salem, Virginia (NRC Region 1) | |
| License number: | VA-161-126-1 |
| Organization: | Virginia Rad Materials Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1354.73 h56.447 days <br />8.064 weeks <br />1.856 months <br />) | |
| Opened: | Michael Welling 14:44 Aug 3, 2011 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Aug 3, 2011 |
| 47121 - NRC Website | |
Lewis Gale Medical Center with Agreement State | |
WEEKMONTHYEARENS 471212011-06-08T04:00:0008 June 2011 04:00:00
[Table view]Agreement State Agreement State Report Involving an Under-Dose 2011-06-08T04:00:00 | |