ENS Event | |
|---|---|
15:30 Jan 8, 2007 | |
| Title | Medical Event Under Dose to Intended Organ Due to Improper Seed Implant |
| Event Description | During a seed implant procedure for treating prostate cancer with I-125 (41 seeds with 0.32 millicuries each), the patient moved after inserting 2 of the 14 treatment needles. The procedure was delayed for five minutes to allow the patient to be more completely under general anesthesia. The lineup was checked using ultrasound and once the urologist, the radiation oncologist, and the medical physicist were comfortable with the situation, the seed implant was resumed. Once the procedure was completed, the hospital personnel took a film shot to verify the needle placement. It was discovered that the 12 of 14 remaining needles that were inserted were not in the intended location.
The patient has been notified of the error. The hospital is in the process of determining the prostate underdose and the overdose to the unintended areas (rectal and urethra). The hospital is still evaluating any patient intervention that needs to be identified and if there is any unintended permanent functional damage to other organs. A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. |
| Where | |
|---|---|
| Hackley Hospital Muskegon, Michigan (NRC Region 3) | |
| License number: | 21-04125-01 |
| Organization: | Hackley Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) 10 CFR 35.3045(a)(3) | |
| Time - Person (Reporting Time:+-0.07 h-0.00292 days <br />-4.166667e-4 weeks <br />-9.5886e-5 months <br />) | |
| Opened: | Carlo Santa Ana 15:26 Jan 8, 2007 |
| NRC Officer: | Jeff Rotton |
| Last Updated: | Jan 8, 2007 |
| 43082 - NRC Website | |
Hackley Hospital with 10 CFR 35.3045(a)(1), 10 CFR 35.3045(a)(3) | |
WEEKMONTHYEARENS 438822007-12-13T05:00:00013 December 2007 05:00:00
[Table view]10 CFR 35.3045(a)(1) Patient Received Less That Prescribed Dose ENS 430822007-01-08T15:30:0008 January 2007 15:30:00 10 CFR 35.3045(a)(1), 10 CFR 35.3045(a)(3) Medical Event Under Dose to Intended Organ Due to Improper Seed Implant 2007-12-13T05:00:00 | |