ENS 45750

v t e ENS Event
05:00 Nov 8, 2005
Title	Agreement State Report - Brachytherapy Dosage Less than Prescribed
Event Description	The following information was obtained from the State of Ohio via email: ODH [Ohio Department of Health] received information on 3/3/10 of a unreported medical event that occurred at Mercy St. Vincent Medical Center in Toledo on 11/8/05. ODH performed an on-site investigation on 3/5/10 and confirmed the unreported medical event. On 11/8/05, the licensee performed a prostate seed implant with 67 I-125 seeds prescribed to deliver a dose of 160 Gray to the prostate. Thirteen seeds were removed from the bladder immediately after the procedure leaving 54 seeds in the patient. A post implant dose calculation showed an under dose to the prostate greater than 20% of the prescribed dose. The licensee then performed an external beam treatment with a linear accelerator to treat the tumor. ODH is continuing the investigation of this event along with other brachytherapy cases performed by the licensee. ODH is also requesting assistance from the NRC's contract medical expert in evaluating the event. Ohio Report Number: OH100003 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 45750 +/-
Where
Mercy St. Vincent Medical Center Toledo, Ohio (NRC Region 3)
License number:	02120490000
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+37954.9 h1,581.454 days <br />225.922 weeks <br />51.991 months <br />)
Opened:	Michael Snee 15:54 Mar 8, 2010
NRC Officer:	Charles Teal
Last Updated:	Mar 8, 2010
45750 - NRC Website
v • d • e

v t e Emergency Notification System
Mercy St. Vincent Medical Center with Agreement State
WEEKMONTHYEAR2005-11-08T05:00:00 [Table view]
[ENS list for Mercy St. Vincent Medical Center]

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