ENS Event | |
|---|---|
05:00 Jul 24, 2014 | |
| Title | Agreement State Report - Medical Underdose |
| Event Description | The following report was received via e-mail:
The licensee performed a prostate Iodine-125 (I-125) seed implant on July 24, 2014. The prescribed dose of 144 Gray (Gy) to 90 percent of the prostate gland (D90) was not within 20 percent of prescribed dose [144 Gy prescribed, 86.1 Gy administered]. The post plan performed on August 12, 2014, demonstrated that the prostate D90 was 59.79 percent, not within 20 percent limit of the prescribed dose. The licensee did not notify the Ohio Department of Health of this occurrence as a medical event. The medical event was discovered as a result of an inspection conducted on 10/28/15. A Notice of Violation for the medical event and failure to report the medical event has been issued to the licensee. The investigation is ongoing. Ohio Report: OH150012 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 | |
|---|---|
| Mercy-Health - Eastgate Medical Center Cincinnati, Ohio (NRC Region 3) | |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+11721 h488.375 days <br />69.768 weeks <br />16.055 months <br />) | |
| Opened: | Stephen James 15:00 Nov 24, 2015 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Nov 24, 2015 |
| 51565 - NRC Website | |
Mercy-Health - Eastgate Medical Center with Agreement State | |
WEEKMONTHYEARENS 515652014-07-24T05:00:00024 July 2014 05:00:00
[Table view]Agreement State Agreement State Report - Medical Underdose 2014-07-24T05:00:00 | |