ENS 40136

v t e ENS Event
15:00 Sep 4, 2003
Title	California Agreement State Report on Medical Event
Event Description	On September 4, 2003, two patients were scheduled for prostate brachytherapy implants. The first was suppose to be implanted with Iodine 125 and the second with Palladium 103. In anticipation of these procedures both the Palladium 103 and Iodine 125 were brought to the surgical suite. The first implant procedure was started and after two strands of Palladium 103 had been implanted it was discovered that an error had been made because the patient was scheduled to be implanted with Iodine 125. The treatment plan had been performed for Iodine 125. The decision was made to continue with the implanting of the Palladium 103 after a new treatment plan was performed. Based on the new plan the appropriate number of Palladium 103 seeds were implanted delivering the prescribed dose. Initial report from (DELETED) was that the patient was scheduled for 7:30 AM, so the event most likely occurred around 8:00 AM. Specific details will be included in his full report to follow. Because the treatment planning equipment was already in the surgical suits, the new plan could be developed with little delay. Specific time frame delays to follow in the full report. The second patient, scheduled for Palladium 103 was in the same day surgery suite and had not been prepped nor given an IV. He was rescheduled for another day, as they did not have enough Palladium 103 for both patients.

ENS 40136 +/-
Where
Little Company Of Mary Hospital Torrance, California (NRC Region 4)
License number:	090503
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+28.73 h1.197 days <br />0.171 weeks <br />0.0394 months <br />)
Opened:	Kathleen Kaufman 19:44 Sep 5, 2003
NRC Officer:	Rich Laura
Last Updated:	Sep 5, 2003
40136 - NRC Website
v • d • e

v t e Emergency Notification System
Little Company Of Mary Hospital with Agreement State
WEEKMONTHYEAR2003-09-04T15:00:00 [Table view]
[ENS list for Little Company Of Mary Hospital]

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