ENS Event | |
|---|---|
04:00 Aug 31, 2004 | |
| Title | Agreement State Report of Medical Misadministration |
| Event Description | Patient scheduled to receive template-guided transperineal prostate interstitial brachytherapy for clinical localized prostate cancer was to receive 72 I-125 seeds, instead received 47 seeds resulting in underexposure of greater than 20%.
The cartridges carrying 15 seeds each were loaded into a 'Mick' applicator. Transrectal ultrasound was used for localization of the prostate and implant needles; fluoroscopy was used very little during the procedure to minimize staff exposure. As each seed was injected into the prostate, it was recorded both on paper and in computer system and final tabulation was 77 seeds were implanted. However, x-rays taken after the procedure showed only 47 seeds had been implanted, although distribution appeared satisfactory. |
| Where | |
|---|---|
| Lahey Clinic Foundation Burlington, Massachusetts (NRC Region 1) | |
| License number: | 44-0015 |
| Organization: | Massachusetts Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1259.43 h52.476 days <br />7.497 weeks <br />1.725 months <br />) | |
| Opened: | Mike Whalen 15:26 Oct 22, 2004 |
| NRC Officer: | Bill Huffman |
| Last Updated: | Oct 22, 2004 |
| 41143 - NRC Website | |
Lahey Clinic Foundation with Agreement State | |
WEEKMONTHYEARENS 495302013-11-12T05:00:00012 November 2013 05:00:00
[Table view]Agreement State Agreement State Report - Access Restricted Due to Technetium-99 Spill ENS 439082008-01-15T05:00:00015 January 2008 05:00:00 Agreement State Massachusetts Agreement State Report - Missing Brachytherapy Seeds ENS 411432004-08-31T04:00:00031 August 2004 04:00:00 Agreement State Agreement State Report of Medical Misadministration 2013-11-12T05:00:00 | |