ENS 43905

v t e ENS Event
06:00 Dec 20, 2007
Title	Agreement State Report - Potential Medical Event - Misplaced Seeds During Prostate Treatment
Event Description	The State provided the following information via facsimile: On January 10, 2008, a 4-week follow up CT-based post prostate seed implant plan was created and reviewed by the prescribing physician. Upon completion of the review it was determined that the seeds had been implanted approximately 2.5cm interior to the base of the prostate. The prescription dose was for 145 Gy to be implanted into the prostate gland using 74 lodine -125 seeds with an average activity of 0.300 milliCuries The post plan dosimetry showed that prostate was under-dosed by greater than 20% from the prescription dose of 145 Gy. The nearby organs at risk, namely the bladder and rectum, were not affected by the misplacement of the seeds. On January 11, 2008, the prescribing physician, [DELETED], notified the attending urologist, [DELETED] of this medical event. The urologist has requested that he notify the patient himself. Item Number: KY082 * * UPDATE FROM CYNTHIA FLANNERY TO JOE O'HARA VIA E-MAIL AT 0651 ON 1/16/08 * * * EN43905 has been reviewed and determined to be a reportable medical event." Notified R1DO(Cobey) and FSME(Flannery) 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.

ENS 43905 +/-
Where
Owensboro Medical Health Systems Owensboro, Kentucky (NRC Region 1)
License number:	202-161-26
Organization:	Kentucky Dept Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+629.58 h26.233 days <br />3.747 weeks <br />0.862 months <br />)
Opened:	Kentucky Dept Of Rad 11:35 Jan 15, 2008
NRC Officer:	Joe O'Hara
Last Updated:	Jan 16, 2008
43905 - NRC Website
v • d • e

v t e Emergency Notification System
Owensboro Medical Health Systems with Agreement State
WEEKMONTHYEAR2007-12-20T06:00:00 [Table view]
[ENS list for Owensboro Medical Health Systems]

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