ENS 44853

v t e ENS Event
08:00 Feb 12, 2009
Title	Brachytherapy Seeds Misplaced in Patient
Event Description	A medical event was discovered on February 12, 2009, for a patient treated at the VA Greater Los Angeles Healthcare System, Los Angeles, California. The medical event involved a patient who had undergone permanent implant prostate seed brachytherapy on February 12, 2009, using iodine-125 seeds. Approximately five seeds were mistakenly placed more than one centimeter from the prostate toward the perineum. This treatment result is interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(3). The causes and clinical effects are under review. At this time, it is not believed that the misplaced seeds will cause any adverse deterministic effects to the patient. The permittee is aware of the requirements in 10 CFR 35.3045 regarding notification of the patient and referring physician. A 15-day written report for the medical event will be submitted to NRC Region III. National Health Physics Program will notify the NRC Project Manager, NRC Region III, of the medical event. The permit number for the facility involved in this medical event is VHA Permit No. 04-00181-04. A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.

ENS 44853 +/-
Where
Va Greater Los Angeles Healthcare System Los Angeles, California (NRC Region 4)
License number:	03-23853-01VA
Organization:	Va National Health Physics Program
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+37.15 h1.548 days <br />0.221 weeks <br />0.0509 months <br />)
Opened:	Edwin Leidholdt 21:09 Feb 13, 2009
NRC Officer:	Pete Snyder
Last Updated:	Feb 13, 2009
44853 - NRC Website
v • d • e

v t e Emergency Notification System
Va Greater Los Angeles Healthcare System with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2009-02-12T08:00:00 [Table view]
[ENS list for Va Greater Los Angeles Healthcare System]

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