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. |
| 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 | |
Greater Los Angeles Healthcare System with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 406342004-03-31T20:00:00031 March 2004 20:00:00
[Table view]10 CFR 35.3045(a)(1) Possible Medical Event 2004-03-31T20:00:00 | |