ENS 53088

v t e ENS Event
08:00 Nov 17, 2017
Title	Agreement State Report - Medical Underdose
Event Description	Eye plaque brachytherapy was being performed using I-125 seeds with a prescribed dose of 85 Gray. After the dose, the Iso-dose curve was noted to be different from the brachytherapy plan i.e. the dose was deeper than expected. Investigation revealed that a new model plaque was used which differed from the previous model. This resulted in an underdose with 65 Gray actually administered. Oregon Report: 17-0073 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 53088 +/-
Where
Oregon Health And Science University Portland, Oregon (NRC Region 4)
License number:	ORE-90013
Organization:	Or Dept Of Health Rad Protection
Reporting

Agreement State
Time - Person (Reporting Time:+127.37 h5.307 days <br />0.758 weeks <br />0.174 months <br />)
Opened:	Daryl Leon 15:22 Nov 22, 2017
NRC Officer:	Mark Abramovitz
Last Updated:	Nov 22, 2017
53088 - NRC Website
v • d • e

v t e Emergency Notification System
Oregon Health And Science University with Agreement State
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