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Event Notification Report for September 2, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/01/2015 - 09/02/2015

** EVENT NUMBERS **

!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State	Event Number: 51342
Rep Org: OHIO BUREAU OF RADIATION PROTECTION Licensee: WOOD COUNTY HOSPITAL Region: 3 City: BOWLING GREEN State: OH County: License #: 02120880005 Agreement: Y Docket: NRC Notified By: STEPHEN JAMES HQ OPS Officer: JEFF ROTTON	Notification Date: 08/25/2015 Notification Time: 10:52 [ET] Event Date: 08/19/2015 Event Time: [EDT] Last Update Date: 08/27/2015
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RICHARD SKOKOWSKI (R3DO) NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

OHIO AGREEMENT STATE REPORT - PROSTATE TREATMENT UNDERDOSE

The following information was provided by the State of Ohio via email:

On 8/20/2015, the Ohio Department of Health (ODH) was notified by voice mail regarding a prostate seed implant to a patient performed on 07/16/2015. This implant consisted of [60] seeds (each seed - 23.6 milliCi of I-125). On 8/18/2015, a post seed implant CT scan was done to verify dose distribution. It was discovered that the D90 "dose" delivered [an under dose] that varied by 34 percent of the prescribed D90 dose for a prostate seed implant. The Referring physician and patient have been notified.

Ohio Item Number: OH150008

* * * RETRACTION PROVIDED FROM STEPHEN JAMES TO JEFF ROTTON VIA EMAIL AT 1454 ON 08/27/2015 * * *

The following information was provided by the State of Ohio via email:

"After additional reporting by the licensee and investigation by ODH, it was determined that the patient did NOT receive the under dose as initially reported and DOES NOT qualify as a medical event. This report is RETRACTED, as of 8/27/15."

Notified R3DO (Skokowski) and NMSS Events Notification 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.

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