ENS 43263

v t e ENS Event
17:00 May 3, 2006
Title	Agreement State Report from Okalahoma - Higher Dose than Prescribed
Event Description	This event took place between 05/03/06 and 03/27/07 and involved ten patients during this time period being treated for prostate cancer using Iodine-125. Kay County Hospital LLC (formally known as Via Cristi Hospital) had changed from ordering I-125 doses in Air-Kerma to millicuries. During the time period from 05/03/06 to 03/27/07 they used the incorrect dose count. This caused each of the ten patients to receive a dose 27 percent higher than the written directive. This did not pose any harm to the patients. The error was discovered on 03/28/07 by a newly hired Medical Physicist. The licensee is in the process of notifying the affected patients. The licensee will also being working with the software vendor to develop better training and procedures for the performance of dose calculations to prevent reoccurrence. * * UPDATE ON 3/30/2007 AT 0720 FROM FLANNERY (NRC/FSME) VIA E-MAIL TO ABRAMOVITZ * * * This event has been reviewed and determined to be a reportable medical event. 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 43263 +/-
Where
Kay County Hospital Llc Ponca City, Oklahoma (NRC Region 4)
License number:	OK-14046-02
Organization:	Ok Deq Rad Management
Reporting

Agreement State
Time - Person (Reporting Time:+7914.62 h329.776 days <br />47.111 weeks <br />10.841 months <br />)
Opened:	Mike Broderick 11:37 Mar 29, 2007
NRC Officer:	John Mackinnon
Last Updated:	Mar 30, 2007
43263 - NRC Website
v • d • e

v t e Emergency Notification System
Kay County Hospital Llc with Agreement State
WEEKMONTHYEAR2006-05-03T17:00:00 [Table view]
[ENS list for Kay County Hospital Llc]

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