ENS Event | |
|---|---|
05:00 May 22, 2014 | |
| Title | Agreement State Report - Patient Overexposure Due To Miscalculation |
| Event Description | The following was received from the State of Nebraska via fax:
At 1430 CDT, the RSO from Nebraska Methodist Hospital called to report a possible overexposure to a patient who had received a prostate treatment of implanted lodine-125 seeds. The RSO, who was also the Medical Physicist on the case, stated that he had mistakenly used the millicurie value for the air kerma value. The treatment dose was intended to be 145 Gray (14,500 rad) but the implant dose was calculated to be 178 Gray (17,800 rad) so the dose differentiated by 27 percent. It is unknown if the target organ (rectum) will exceed 50 rem. Nebraska Item Number: NE140004
The following was received from the State of Nebraska via email: In a letter dated June 3, 2014, the RSO/Medical Physicist from Nebraska Methodist Hospital updated the information for this incident. The implanted dose was 184 Gray. The dose to the organ at risk (rectum) is as follows: Only a small percentage of the entire organ (rectum) was imaged and contoured, in the plan that was 12cc. An estimate of the increased dose ranges from 16 Gray in the highest dose regions comprising 90% of the contoured volume and 27 Gray in the highest dose regions comprising 30% of the contoured volume. The patient was informed within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of the discovery of the misadministration. Notified R4DO (Hay) and FSME Event Resource 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 | |
|---|---|
| Nebraska Methodist Hospital Lincoln, Nebraska (NRC Region 4) | |
| License number: | 01-07-02 |
| Organization: | Ne Div Of Radioactive Materials |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+35.08 h1.462 days <br />0.209 weeks <br />0.0481 months <br />) | |
| Opened: | Howard Shuman 16:05 May 23, 2014 |
| NRC Officer: | Daniel Mills |
| Last Updated: | Jun 16, 2014 |
| 50135 - NRC Website | |
Nebraska Methodist Hospital with Agreement State | |
WEEKMONTHYEARENS 501352014-05-22T05:00:00022 May 2014 05:00:00
[Table view]Agreement State Agreement State Report - Patient Overexposure Due to Miscalculation 2014-05-22T05:00:00 | |