ENS 45206

v t e ENS Event
04:00 Mar 15, 2009
Title	Medical Underexposure During Brachytherapy
Event Description	A prostate seed implant was performed on March 5th, 2009, using needles preloaded with I-125 seeds. After implanting a total of 61 seeds, 22 seeds were found and then retrieved from the bladder. The patient later returned for a pelvic CT for post implant dosimetry. This dosimetry revealed an under dosing of the prostate with a D90 dose less than 80% of the prescribed dose. The seed distribution error was caused by the position of the needles in respect to depth when the seeds were released. The patient received no ill effect, but requires further therapeutic radiation in order to complete the prescription. The patient is currently scheduled for a second seed implant to complete the therapy. 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 45206 +/-
Where
Nanticoke Cook Memorial Hospital Seaford, Delaware (NRC Region 1)
License number:	07-17618-01
Organization:	Nanticoke Cook Memorial Hospital
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+2936.9 h122.371 days <br />17.482 weeks <br />4.023 months <br />)
Opened:	Matthew Rajotte 12:54 Jul 15, 2009
NRC Officer:	Charles Teal
Last Updated:	Jul 15, 2009
45206 - NRC Website
v • d • e

v t e Emergency Notification System
Nanticoke Cook Memorial Hospital with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2009-03-15T04:00:00 [Table view]
[ENS list for Nanticoke Cook Memorial Hospital]

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