ENS Event | |
|---|---|
06:00 Aug 6, 2009 | |
| Title | Agreement State Report - Medical Dose Different than Prescribed |
| Event Description | The following was received from the state via e-mail:
This incident was reported by a medical licensee (Centura Health Penrose - St. Francis Health Services License # 197-02) on 08/06/2009. On 22 July 2009, at patient at Penrose Hospital was implanted with 70 Palladium-103 seeds, 2.5 U each on that day. The application was via a Mick applicator, using intra-operative planning with a Variseed planning system. It was noted on the C arm film taken at the completion of the implant that there was some clumping of the seeds in groups. A post implant CT scan was done on 23 July 2009. The results of the computerized dosimetry plan was evaluated on the 5 August 2009 and it was determined that the prostate gland was under dosed, receiving a dose to 90% of the prostate volume (D90) of 36.6% of the prescribed 125 Gy. The AU [Authorized User] written directive listed an expected range of D90 to be 90% to 135%. The discrepancy between actual dose and prescribed falls outside of the 20% tolerance for delivered dose according to [Colorado State Regulation] RH 7.21.1.1 (1). A full report is expected from the licensee within 30 days. 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 | |
|---|---|
| Centura Health Penrose - St. Francis Health Services Colorado Springs, Colorado (NRC Region 4) | |
| License number: | 197-02 |
| Organization: | Colorado Dept Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+321.17 h13.382 days <br />1.912 weeks <br />0.44 months <br />) | |
| Opened: | James Grice 15:10 Aug 19, 2009 |
| NRC Officer: | Karl Diederich |
| Last Updated: | Aug 19, 2009 |
| 45275 - NRC Website | |
Centura Health Penrose - St. Francis Health Services with Agreement State | |
WEEKMONTHYEARENS 452752009-08-06T06:00:0006 August 2009 06:00:00
[Table view]Agreement State Agreement State Report - Medical Dose Different than Prescribed ENS 452212009-07-22T06:00:00022 July 2009 06:00:00 Agreement State Agreement State Report - Medical Event 2009-08-06T06:00:00 | |