ENS 41210

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v t e ENS Event
06:00 Nov 18, 2004
Title	Agreement State Report Involving a Therapy Misadministration
Event Description	The following information was provided via email from the Radioactive Materials Branch Director, Division of Radiological Health, MS State Dept. of Health: On November 18, 2004, licensee's RSO notified Division of Radiological Health/MS State Dept. of Health, of a Iodine-125 therapy misadministration. The prescribed treatment was for 145 gray to the prostate gland; however, due to an error concerning the coordinates, the treatment area was partially missed and resulted in a greater than 10 gray treatment to the rectum. The isotope was Iodine -125, 88 seeds with average activity of .300 millicuries, total activity of 26.8 millicuries. The patient was notified of the error and agreed to have the treatment performed again with no problems occurring. The RSO notified DRH after discussing the error with the authorized user and agreeing on corrective actions to prevent reoccurrence. At the present time, this is all the information we have received. I will update as soon as possible. * * UPDATE PROVIDED BY SMITH TO JEFF ROTTON AT 1738 EST ON 12/08/04 * * * The following update information was provided via email from MS State Department of Health: The cause of the misadministration appears to be a misinterpretation to an ultrasound image which resulted in the needle being inserted in the wrong area. This caused a lower dose to be administered to the prostate gland greater than 20 % dose of the prescribed dose. Corrective actions will require a fIuoroscopticimage to verify the coordinates and confirm needle placement. Notified R1DO (Anderson) and NMSS EO (Giitter)

ENS 41210 +/-
Where
Baptist Memorial Hospital - North Mississippi Mississippi (NRC Region 1)
License number:	MS-232-02
Organization:	Mississippi Div Of Rad Health
Reporting

Agreement State
Time - Person (Reporting Time:+30.6 h1.275 days <br />0.182 weeks <br />0.0419 months <br />)
Opened:	Bobby Smith 12:36 Nov 19, 2004
NRC Officer:	Steve Sandin
Last Updated:	Dec 8, 2004
41210 - NRC Website
v • d • e

v t e Emergency Notification System
Baptist Memorial Hospital - North Mississippi with Agreement State
WEEKMONTHYEAR2004-11-18T06:00:00 [Table view]
[ENS list for Baptist Memorial Hospital - North Mississippi]

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ENS Notification