Event Notification Report for June 04, 2009
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/03/2009 - 06/04/2009
EVENT NUMBERS
47980
Agreement State
Event Number: 47980
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: OWENSBORO MEDICAL HEALTH SYSTEM
Region: 1
City: OWENSBORO State: KY
County:
License #: 202-161-26
Agreement: Y
Docket:
NRC Notified By: MICHELE GREENWELL
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: OWENSBORO MEDICAL HEALTH SYSTEM
Region: 1
City: OWENSBORO State: KY
County:
License #: 202-161-26
Agreement: Y
Docket:
NRC Notified By: MICHELE GREENWELL
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/31/2012
Notification Time: 15:20 [ET]
Event Date: 06/04/2009
Event Time: 00:00 [CDT]
Last Update Date: 06/05/2012
Notification Time: 15:20 [ET]
Event Date: 06/04/2009
Event Time: 00:00 [CDT]
Last Update Date: 06/05/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE
AGREEMENT STATE REPORT - THREE MEDICAL EVENTS DISCOVERED DURING AN INSPECTION
The following report was received via e-mail:
"During a routine inspection, three unreported [prostate brachytherapy] medical events were identified.
"Case One:
Implant Date: 6/4/2009
Prescribed dose: 145Gy to the prostate
Post implant CT dosimetry: V100 (the volume of the prostate receiving 100% of the prescribed dose) totaled 69.71%
Source: I-125 encapsulated seeds
Vendor: IsoAid
Model Number: IAI-125A
Activity per seed: 0.330 mCi
Number of seeds implanted: 69
"Case Two:
Implant Date: 6/19/2009
Prescribed dose: 145Gy to the prostate
Post implant CT dosimetry: V100 (the volume of the prostate receiving 100% of the prescribed dose) totaled 62.77%
Source: I-125 encapsulated seeds
Vendor: IsoAid
Model Number: IAI-125A
Activity per seed: 0.330 mCi
Number of seeds implanted: 80
"Case Three:
Implant Date: 10/29/2009
Prescribed dose: 145Gy to the prostate
Post implant CT dosimetry: V100 (the volume of the prostate receiving 100% of the prescribed dose) totaled 65.34%
Source: I-125 encapsulated seeds
Vendor: IsoAid
Model Number: IAI-125A
Activity per seed: 0.330 mCi
Number of seeds implanted: 84
* * * UPDATE FROM CURT PENDERGRASS TO HOWIE CROUCH VIA EMAIL ON 6/5/12 AT 1018 EDT * * *
"D90 is defined as minimum dose received by 90% of CT-defined prostate volume
Case 1 D90 = 72.80% of 145Gy
Case 2 D90 = 58.86% of 145Gy
Case 3 D90 = 54.00% of 145Gy"
Notified R1DO (Cahill) and FSME Events via email.
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.
The following report was received via e-mail:
"During a routine inspection, three unreported [prostate brachytherapy] medical events were identified.
"Case One:
Implant Date: 6/4/2009
Prescribed dose: 145Gy to the prostate
Post implant CT dosimetry: V100 (the volume of the prostate receiving 100% of the prescribed dose) totaled 69.71%
Source: I-125 encapsulated seeds
Vendor: IsoAid
Model Number: IAI-125A
Activity per seed: 0.330 mCi
Number of seeds implanted: 69
"Case Two:
Implant Date: 6/19/2009
Prescribed dose: 145Gy to the prostate
Post implant CT dosimetry: V100 (the volume of the prostate receiving 100% of the prescribed dose) totaled 62.77%
Source: I-125 encapsulated seeds
Vendor: IsoAid
Model Number: IAI-125A
Activity per seed: 0.330 mCi
Number of seeds implanted: 80
"Case Three:
Implant Date: 10/29/2009
Prescribed dose: 145Gy to the prostate
Post implant CT dosimetry: V100 (the volume of the prostate receiving 100% of the prescribed dose) totaled 65.34%
Source: I-125 encapsulated seeds
Vendor: IsoAid
Model Number: IAI-125A
Activity per seed: 0.330 mCi
Number of seeds implanted: 84
* * * UPDATE FROM CURT PENDERGRASS TO HOWIE CROUCH VIA EMAIL ON 6/5/12 AT 1018 EDT * * *
"D90 is defined as minimum dose received by 90% of CT-defined prostate volume
Case 1 D90 = 72.80% of 145Gy
Case 2 D90 = 58.86% of 145Gy
Case 3 D90 = 54.00% of 145Gy"
Notified R1DO (Cahill) and FSME Events via email.
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.