ENS Event | |
|---|---|
20:30 May 21, 2009 | |
| Title | Medical Event Involving a Dose That Is Different than Prescribed |
| Event Description | The patient was undergoing brachytherapy treatment of the prostate. After 6 seeds were implanted, the procedure was aborted because of concerns in placing additional needles into the patient. The prescribed dose was 145 Gy. However, only 6 of 88 prescribed seeds were implanted. Each seed total activity is 0.288 mCi of I-125.
Family members were notified of the aborted procedure. 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.
This event is being retracted because the physician made a choice to terminate the brachytherapy treatment of the prostate to the patient. The physician then rewrote the procedure to the patient to limit the prescribed number of seeds to 6. Having 6 seeds implanted into the patient the prescribed dose was now met under the new directive. Notified R3DO (Richard Skokowski) , FSME(Lydia Chang) |
| Where | |
|---|---|
| St. Johns Mercy Medical Center St. Louis, Missouri (NRC Region 3) | |
| License number: | 24-0079403 |
| Organization: | St. Johns Mercy Medical Center |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+13.35 h0.556 days <br />0.0795 weeks <br />0.0183 months <br />) | |
| Opened: | Robert Turco 09:51 May 22, 2009 |
| NRC Officer: | Vince Klco |
| Last Updated: | May 22, 2009 |
| 45089 - NRC Website | |
St. Johns Mercy Medical Center with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 450892009-05-21T20:30:00021 May 2009 20:30:00
[Table view]10 CFR 35.3045(a)(1) Medical Event Involving a Dose That Is Different than Prescribed ENS 414832005-03-09T14:35:0009 March 2005 14:35:00 10 CFR 35.3045(a)(1) Incorrect Dose Given to an Infant 2009-05-21T20:30:00 | |