ENS Event | |
|---|---|
17:00 Mar 23, 2007 | |
| Title | Potential Overexposure Involving Brachytherapy Source |
| Event Description | At 1300 hours0.015 days <br />0.361 hours <br />0.00215 weeks <br />4.9465e-4 months <br /> on 3/23/07, a male patient received I-125 seed implants for treatment of prostate cancer. The RSO received a call at approximately 1730 hours0.02 days <br />0.481 hours <br />0.00286 weeks <br />6.58265e-4 months <br /> from the Radiation Oncologist Physicist who had identified that the wrong units were input into the dose planning computer. This resulted in a potential overexposure. A CAT scan is scheduled for Monday, 3/26/07, to verify source placement and more accurately calculate the overexposure. At this time, the preliminary information provided indicates a prescribed dose of 145 Gray with an estimated dose delivery of 155 Gray. The licensee does not believe that there will be any adverse effects to the patient. Following the more accurate calculation the licensee will review whether this notification meets the reporting criteria.
The licensee has notified the prescribing physician of the error. 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.
This event is retracted by the licensee. Since the time of the original notification the licensee has established, by dosimetry readings, that the exposure was below the reporting criteria. Notified R1DO (Dimitriadis) and FSME EO (Morell). |
| Where | |
|---|---|
| Lancaster General Hospital Lancaster, Pennsylvania (NRC Region 1) | |
| License number: | 37-1186-01 |
| Organization: | Lancaster General Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+2.5 h0.104 days <br />0.0149 weeks <br />0.00342 months <br />) | |
| Opened: | Anthony Montagenese 19:30 Mar 23, 2007 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Mar 28, 2007 |
| 43256 - NRC Website | |
Lancaster General Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 432562007-03-23T17:00:00023 March 2007 17:00:00
[Table view]10 CFR 35.3045(a)(1) Potential Overexposure Involving Brachytherapy Source ENS 419282005-08-18T14:00:00018 August 2005 14:00:00 10 CFR 35.3045(a)(1) Medical Event 2007-03-23T17:00:00 | |