ENS 46572

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v t e ENS Event
05:00 Dec 8, 2010
Title	Agreement State Report - Potential Underdose to Patient Due to Aborted Treatment
Event Description	The following information was received from the State of Ohio by email: Written directive called for Iodine-125 radioactive seed implant of the prostate with 142 seeds, 0.477 mCi each, total activity 67.7 mCi. Transperineal implantation of the needles were attempted on 12/8/10. After placement of four needles (8 sources) in the first (anterior-most) row, it was subsequently noted that patient's pelvic inlet was too narrow for adequate placement of the lateral two columns of seeds after repeated attempts. Authorized User Physician decided to abort procedure at this point. Patient was taken to the recovery room in satisfactory condition. Patient was notified at time of event. Radiation Safety Officer was not notified at time of event. Licensee's RSO discovered event during QMP review on morning of 1/25/11 and notified ODH [Ohio Department of Health] by telephone and e-mail that afternoon. ODH inspector will visit licensee's location on 1/31/11. Given: Radionuclide: I-125; Activity: 3.2 mCi (118.4 MBq); Dose: 81.1 rad (0.811 Gy). Intended: Radionuclide: I-125; Activity: 67.7 mCi (2504.9 MBq); Dose: 14400 rad (144 Gy). The source used was a Brachytherapy sealed source I-125; Model Number STM-1251; Serial Number 2357321SO; Activity .477 Ci (17.649 GBq). Ohio number: OH110001 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.

ENS 46572 +/-
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:+1181.23 h49.218 days <br />7.031 weeks <br />1.618 months <br />)
Opened:	Stephen James 10:14 Jan 26, 2011
NRC Officer:	Dong Park
Last Updated:	Jan 26, 2011
46572 - NRC Website
v • d • e

v t e Emergency Notification System
Cleveland Clinic Foundation with Agreement State
WEEKMONTHYEAR2021-03-26T18:00:00 [Table view]
[ENS list for Cleveland Clinic Foundation]

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ENS Notification