ENS Event | |
|---|---|
05:00 Nov 27, 2012 | |
| Title | Agreement State Report - Underdose To Prescribed Treatment Location Following A Brachytherapy Treatment |
| Event Description | The following information was provided via e-mail from the State of Ohio Bureau of Radiation Protection:
At 3:10 PM on Dec 13, 2012 the licensee RSO called the Ohio Department of Health Bureau to report a medical event involving a prostate seed underdose. A prostate seed implant procedure performed on 11/27/2012 was found to have failed the prescribed dose-volume criteria via post-implant CT performed on 12/10/2012. The target prescription was 160 Gy to the prostate. The patient was implanted with 88 Iodine-125 seeds with a total activity of 33.44 mCi (0.38 mCi / seed). The post-implant dosimetry was shown to have a D90 of ~40% of the prescription dose with a number of seeds outside of the prostate. The actual implanted activity in the prostate gland was 27.36 mCi. Sixteen seeds were found in the perineum outside the target volume of the prostate + 1 cm as PTV. The dose to this area unintended to receive radiation was about 20Gy to the periphery of the contour volume containing all the 16 seeds. The physician was informed of the discrepancy on 12/12/2012 and the patient was informed on 12/13/2012. There is no negative impact expected to the patient, the physician indicates. The patient will be re-implanted to correct for the D90 discrepancy. The Bureau of Radiation Protection will be sending an inspector the week of December 17 to investigate the incident." Ohio Report Reference Number: 2012-040 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 | |
|---|---|
| University Of Toledo Toledo, Ohio (NRC Region 3) | |
| License number: | 02110490006 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+414 h17.25 days <br />2.464 weeks <br />0.567 months <br />) | |
| Opened: | Karl Von Ahn 11:00 Dec 14, 2012 |
| NRC Officer: | Bill Huffman |
| Last Updated: | Dec 14, 2012 |
| 48592 - NRC Website | |
University Of Toledo with Agreement State | |
WEEKMONTHYEARENS 485922012-11-27T05:00:00027 November 2012 05:00:00
[Table view]Agreement State Agreement State Report - Underdose to Prescribed Treatment Location Following a Brachytherapy Treatment ENS 475772012-01-06T05:00:0006 January 2012 05:00:00 Agreement State Agreement State Report Involving a Potential Medical Event During Brachytherapy 2012-11-27T05:00:00 | |