ENS 40634

v t e ENS Event
20:00 Mar 31, 2004
Title	Possible Medical Event
Event Description	The U.S. Department of Veteran's Affairs Health Physics Program (VA NHPP) notified the NRC of the following possible Medical Event at the VA Greater Los Angeles Healthcare System (GLAHCS), 11301 Wilshire Boulevard, Los Angeles, California 90073, a master material license permittee. On March 31, 2004, a permanent-implant prostate brachytherapy procedure was performed. 109 Iodine-125 seeds were implanted in the patient. A number of seeds were mistakenly placed in the patient's bladder. The seeds placed in the bladder have been recovered. At this time, it appears that the dose to the prostate was more than 20 percent less than that prescribed. The VA GLAHCS has taken initial action to prevent a recurrence. The VA NHPP intends to conduct a reactive inspection next week. The VA NHPP is in the process of verifying that the licensee notified the patient of this occurrence. Initial action taken to prevent recurrence was to cease performing this procedure until an investigation and root cause determination are complete. The licensee has not yet determined whether any unintended damage was done to the bladder as a result of this procedure.

ENS 40634 +/-
Where
Greater Los Angeles Healthcare System Los Angeles, California (NRC Region 4)
License number:	03-23853-01VA
Organization:	U.S. Dept Of Va Hp Program
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+45.67 h1.903 days <br />0.272 weeks <br />0.0626 months <br />)
Opened:	Edwin M. Leinholdt, Phd 17:40 Apr 2, 2004
NRC Officer:	Eric Thomas
Last Updated:	Apr 2, 2004
40634 - NRC Website
v • d • e

v t e Emergency Notification System
Greater Los Angeles Healthcare System with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2004-03-31T20:00:00 [Table view]
[ENS list for Greater Los Angeles Healthcare System]

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