ENS Event | |
|---|---|
17:00 Dec 15, 2003 | |
| Title | Medical Event |
| Event Description | During a Health Physics audit, while reviewing seed implantation cases, the auditor was reviewing a procedure performed on a patient on 2/13/04. The procedure involved an I-125 seed implantation that delivered 5000 Rad to the patient's prostate. The auditor saw a notation in the record that a previous implantation on 12/15/03 had also delivered 5000 Rad to the same patient's prostate.
When the auditor pulled the record for the 12/15/03 implantation, he discovered that the intended dose from the procedure was 10,000 Rad. He proceeded to call Radiation Medicine Center, the licensee who performed both procedures (License # 2902023-06). Radiation Medicine Center stated that, when evaluating the patient in mid-January, they discovered, via CT scan and dosimetry, that the patient had only received 5000 Rad during the first procedure, and that is why the second procedure was performed on 2/13/04. The auditor is reporting the implantation from 12/15/03 as a Medical Event.
The licensee is retracting this event on the basis that further investigation along with consultation and a site visit with Reg 1 NRC personnel determined the implant went as planned. There was some tissue shrinkage resulting in cold spots which were adequately treated in the second implant on 02/13/04. Notified Reg 1 RDO(Cobey) and NMSS EO(Psyk) |
| Where | |
|---|---|
| St. Mary Hospital Hoboken, New Jersey (NRC Region 1) | |
| License number: | 2901024-01 |
| Organization: | St. Mary Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+1750.72 h72.947 days <br />10.421 weeks <br />2.398 months <br />) | |
| Opened: | Ira Garelick 15:43 Feb 26, 2004 |
| NRC Officer: | Eric Thomas |
| Last Updated: | Mar 9, 2004 |
| 40549 - NRC Website | |
St. Mary Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 405492003-12-15T17:00:00015 December 2003 17:00:00
[Table view]10 CFR 35.3045(a)(1) Medical Event 2003-12-15T17:00:00 | |