ENS Event | |
|---|---|
21:00 Mar 4, 2004 | |
| Title | The Cleveland Clinic Foundation Administered An Underdose During A Therapeutic Treatment |
| Event Description | During a therapeutic procedure using I-125 Gliasite from 2/28 - 3/1, the state licensee administered an under dose of 24%. The therapist calculated a dwell time of only 97 hours0.00112 days <br />0.0269 hours <br />1.603836e-4 weeks <br />3.69085e-5 months <br /> when the prescribed dwell time was 120 hrs for treating a brain tumor. This resulted in the patient receiving 5,300 rads instead of the prescribed 7,000 rads. Both the patient and the referring physician were notified. The licensee will make up for the under dosage by using a linear accelerator. |
| Where | |
|---|---|
| Cleveland Clinic Foundation Cleveland, Ohio (NRC Region 3) | |
| License number: | 02110180013 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+85.25 h3.552 days <br />0.507 weeks <br />0.117 months <br />) | |
| Opened: | Mark Light 10:15 Mar 8, 2004 |
| NRC Officer: | Chauncey Gould |
| Last Updated: | Mar 8, 2004 |
| 40575 - NRC Website | |
Cleveland Clinic Foundation with Agreement State | |
WEEKMONTHYEARENS 551572021-03-26T18:00:00026 March 2021 18:00:00
[Table view]Agreement State Medical Event Report - Underdosage ENS 536722018-10-16T04:00:00016 October 2018 04:00:00 Agreement State En Revision Imported Date 7/24/2019 ENS 498152014-01-24T05:00:00024 January 2014 05:00:00 Agreement State Agreement State Report - Medical Event Involving Unintended Dose ENS 470712011-07-12T15:00:00012 July 2011 15:00:00 Agreement State Agreement State Report - Patient Received Treatment to Incorrect Organ ENS 465722010-12-08T05:00:0008 December 2010 05:00:00 Agreement State Agreement State Report - Potential Underdose to Patient Due to Aborted Treatment ENS 463762010-10-29T04:00:00029 October 2010 04:00:00 Agreement State Agreement State - Dose Delivered to Wrong Organ ENS 462862010-09-27T04:00:00027 September 2010 04:00:00 Agreement State Ohio Agreement State Report - 95% Medical Underdosage Due to Equipment Failure ENS 443972008-08-07T18:00:0007 August 2008 18:00:00 Agreement State Agreement State Report - Underexposure During Hdr Medical Treatment Due to Equipment Malfunction ENS 405752004-03-04T21:00:0004 March 2004 21:00:00 Agreement State the Cleveland Clinic Foundation Administered an Underdose During a Therapeutic Treatment 2021-03-26T18:00:00 | |