l am calling per
10 CFR 35.3045 to notify you of a possible medical event at the
VA Medical Center, Philadelphia,
Pennsylvania. On October 3, 2005 a permanent implant prostate
brachytherapy procedure was performed at the medical center. A written directive prescribed 90
Iodine 125 seeds to be implanted in the patient's prostate.
However, 45 of the seeds were implanted mistakenly in bladder. The seeds were recovered from the bladder prior to completion of the procedure in the operating room.
The written directive was revised by the authorized user prior to completion of the procedure in the operating room to document the actual number of seeds implanted in the prostate (45).
Based on dosimetry calculations performed October 4, 2005, a medical event may have occurred since the dose to the prostate and other tissues may differ from that originally prescribed in the written directive by values greater than those given in 10 CFR 35.3045.
These circumstances appear to be similar to a previously reported event (Event No. 39586), which NRC ultimately decided did not represent a medical event.
However, the NHPP has decided conservatively to perform an on-site review at the medical center next week to assess the particular circumstances of this event.
At the time of this report the licensee did not know why the event happened but will be investigating to determine the cause and the significance on 10/13/2005. The licensee stated that the patient was notified of the situation.
- * * RETRACTION AT 14:05 EST ON 2/3/2006 FROM GARY WILLIAMS TO ABRAMOVITZ * * *
Based on our discussions with NRC Region III, the circumstances for event do not meet the definition in 10CFR35.3045 as a medical event.
Contacted the R1DO (Meyer), R3DO (Riemer), and
NMSS EO (Morell).