ENS 46572
ENS Event | |
|---|---|
05:00 Dec 8, 2010 | |
| Title | Agreement State Report - Potential Underdose to Patient Due to Aborted Treatment |
| Event Description | The following information was received from the State of Ohio by email:
Written directive called for Iodine-125 radioactive seed implant of the prostate with 142 seeds, 0.477 mCi each, total activity 67.7 mCi. Transperineal implantation of the needles were attempted on 12/8/10. After placement of four needles (8 sources) in the first (anterior-most) row, it was subsequently noted that patient's pelvic inlet was too narrow for adequate placement of the lateral two columns of seeds after repeated attempts. Authorized User Physician decided to abort procedure at this point. Patient was taken to the recovery room in satisfactory condition. Patient was notified at time of event. Radiation Safety Officer was not notified at time of event. Licensee's RSO discovered event during QMP review on morning of 1/25/11 and notified ODH [Ohio Department of Health] by telephone and e-mail that afternoon. ODH inspector will visit licensee's location on 1/31/11. Given: Radionuclide: I-125; Activity: 3.2 mCi (118.4 MBq); Dose: 81.1 rad (0.811 Gy). Intended: Radionuclide: I-125; Activity: 67.7 mCi (2504.9 MBq); Dose: 14400 rad (144 Gy). The source used was a Brachytherapy sealed source I-125; Model Number STM-1251; Serial Number 2357321SO; Activity .477 Ci (17.649 GBq). Ohio number: OH110001 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 | |
|---|---|
| Cleveland Clinic Foundation Cleveland, Ohio (NRC Region 3) | |
| License number: | 02110180013 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1181.23 h49.218 days <br />7.031 weeks <br />1.618 months <br />) | |
| Opened: | Stephen James 10:14 Jan 26, 2011 |
| NRC Officer: | Dong Park |
| Last Updated: | Jan 26, 2011 |
| 46572 - NRC Website | |
Cleveland Clinic Foundation with Agreement State | |
WEEKMONTHYEARENS 551572021-03-26T18:00:00026 March 2021 18:00:00
[Table view]Agreement State Medical Event Report - Underdosage ENS 536722018-10-16T04:00:00016 October 2018 04:00:00 Agreement State En Revision Imported Date 7/24/2019 ENS 498152014-01-24T05:00:00024 January 2014 05:00:00 Agreement State Agreement State Report - Medical Event Involving Unintended Dose ENS 470712011-07-12T15:00:00012 July 2011 15:00:00 Agreement State Agreement State Report - Patient Received Treatment to Incorrect Organ ENS 465722010-12-08T05:00:0008 December 2010 05:00:00 Agreement State Agreement State Report - Potential Underdose to Patient Due to Aborted Treatment ENS 463762010-10-29T04:00:00029 October 2010 04:00:00 Agreement State Agreement State - Dose Delivered to Wrong Organ ENS 462862010-09-27T04:00:00027 September 2010 04:00:00 Agreement State Ohio Agreement State Report - 95% Medical Underdosage Due to Equipment Failure ENS 443972008-08-07T18:00:0007 August 2008 18:00:00 Agreement State Agreement State Report - Underexposure During Hdr Medical Treatment Due to Equipment Malfunction ENS 405752004-03-04T21:00:0004 March 2004 21:00:00 Agreement State the Cleveland Clinic Foundation Administered an Underdose During a Therapeutic Treatment 2021-03-26T18:00:00 | |