ENS 45089

v t e 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. * * UPDATE FROM ROBERT TURCO TO JOHN KNOKE AT 1643 EDT ON 5/22/09 * * * 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)

ENS 45089 +/-
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
v • d • e

v t e Emergency Notification System
St. Johns Mercy Medical Center with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2009-05-21T20:30:00 [Table view]
[ENS list for St. Johns Mercy Medical Center]

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