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
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. |
| 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 | |
Owensboro Medical Health Systems with Agreement State | |
WEEKMONTHYEARENS 439052007-12-20T06:00:00020 December 2007 06:00:00
[Table view]Agreement State Agreement State Report - Potential Medical Event - Misplaced Seeds During Prostate Treatment 2007-12-20T06:00:00 | |