ENS Event | |
|---|---|
05:00 Jun 4, 2009 | |
| Title | Agreement State Report - Three Medical Events Discovered During an Inspection |
| Event Description | The following report was received via e-mail:
During a routine inspection, three unreported [prostate brachytherapy] medical events were identified. Case One: Implant Date: 6/4/2009 Prescribed dose: 145Gy to the prostate Post implant CT dosimetry: V100 (the volume of the prostate receiving 100% of the prescribed dose) totaled 69.71% Source: I-125 encapsulated seeds Vendor: IsoAid Model Number: IAI-125A Activity per seed: 0.330 mCi Number of seeds implanted: 69 Case Two: Implant Date: 6/19/2009 Prescribed dose: 145Gy to the prostate Post implant CT dosimetry: V100 (the volume of the prostate receiving 100% of the prescribed dose) totaled 62.77% Source: I-125 encapsulated seeds Vendor: IsoAid Model Number: IAI-125A Activity per seed: 0.330 mCi Number of seeds implanted: 80 Case Three: Implant Date: 10/29/2009 Prescribed dose: 145Gy to the prostate Post implant CT dosimetry: V100 (the volume of the prostate receiving 100% of the prescribed dose) totaled 65.34% Source: I-125 encapsulated seeds Vendor: IsoAid Model Number: IAI-125A Activity per seed: 0.330 mCi Number of seeds implanted: 84
D90 is defined as minimum dose received by 90% of CT-defined prostate volume Case 1 D90 = 72.80% of 145Gy Case 2 D90 = 58.86% of 145Gy Case 3 D90 = 54.00% of 145Gy Notified R1DO (Cahill) and FSME Events via email. 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 | |
|---|---|
| Owensboro Medical Health System Owensboro, Kentucky (NRC Region 1) | |
| License number: | 202-161-26 |
| Organization: | Kentucky Dept Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+26218.33 h1,092.43 days <br />156.061 weeks <br />35.914 months <br />) | |
| Opened: | Michele Greenwell 15:20 May 31, 2012 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Jun 5, 2012 |
| 47980 - NRC Website | |
Owensboro Medical Health System with Agreement State | |
WEEKMONTHYEARENS 485932012-10-30T06:00:00030 October 2012 06:00:00
[Table view]Agreement State Medical Event Involving Permanent Prostate Brachytherapy Implant ENS 479802009-06-04T05:00:0004 June 2009 05:00:00 Agreement State Agreement State Report - Three Medical Events Discovered During an Inspection 2012-10-30T06:00:00 | |