ENS 39586

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v t e ENS Event
05:00 Feb 3, 2003
Title	Possible Medical Event at Philadelphia Veterans Administration Medical Center
Event Description	Informed by a representative of the Department of Veteran's Affairs National Health Physics Program (NHPP) that a possible medical event may have occurred at the Philadelphia Veterans Administration Medical Center. The event took place on February 3, 2003 but was not determined until it was discussed on February 13, 2003. The procedure being performed at the time of the event was a permanent prostate seed implant brachytherapy. The nuclide involved is I-125. A fraction of the seeds intended to be implanted into the prostate were recovered from the bladder. The medical authorized user (the physician prescribing and performing the procedure) rewrote the written directive in the operating room to reflect the number of seeds that were successfully implanted into the prostate. Calculations are presently being made to determine the exposure to the bladder. Preliminary calculations indicate that there are no deterministic effects to the patient as a result of the event. All the seeds are presently accounted for. There was no patient intervention. The NHPP is currently investigating the event. * * RETRACTION AT 14:05 EST ON 2/3/2006 FROM GARY WILLIAMS TO ABRAMOVITZ * * * Based on our discussions with NRC Region III, the circumstances for event do not meet the definition in 10CFR35.3045 as a medical event. Contacted the R1DO (Meyer), R3DO (Riemer), and NMSS EO (Morell).

ENS 39586 +/- *RETRACTED*
Where
Philadelphia Va Medical Center Philadelphia, Pennsylvania (NRC Region 1)
License number:	37-00062-07
Organization:	Department Of Veterans Affairs
Reporting

10 CFR 35.3045(a)(3)
Time - Person (Reporting Time:+273.53 h11.397 days <br />1.628 weeks <br />0.375 months <br />)
Opened:	Paul Yurko 14:32 Feb 14, 2003
NRC Officer:	Howie Crouch
Last Updated:	Feb 3, 2006
39586 - NRC Website
v • d • e

v t e Emergency Notification System
Philadelphia Va Medical Center with 10 CFR 35.3045(a)(3)
WEEKMONTHYEAR2003-02-03T05:00:00 [Table view]
[ENS list for Philadelphia Va Medical Center]

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