ENS 45595

v t e ENS Event
05:00 Nov 19, 2009
Title	Agreement State Report - Braychytherapy Dose Differed from the Prescribed Dose by More than 20%
Event Description	The following was received via facsimile: During a prostrate brachytherapy procedure using a Mick applicator and I-125 sources, 41 of 41 sources were implanted into the patient's perineal soft tissue, inferior to the prostrate [resulting in:] 1. Dose was greater than 5 rem effective dose equivalent, and/or 50 rem to an organ or tissue and 2. the total dose delivered differs from the prescribed dose by 20% or more. Explain the effect, if any, on the individual who received the administration: Possible perineal soft tissue fibrosis. The patient is currently without symptoms six weeks following the implant. Additional notes: Licensee's evaluation of why the event occurred: Visualization of the prostrate was difficult on ultrasound due to poor image quality, leading to needle placement inferior to the prostrate. What actions, if any, have been taken or are planned to prevent recurrence: Discontinuation of the procedure if the locations of the needles are not known to relative certainty. The patient and the referring physician were notified [of this event]. No follow-up is required. NC Incident Report Number: 09-63 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 45595 +/-
Where
Lake Norman Regional Medical Center Mooresville, North Carolina (NRC Region 1)
Organization:	Nc Div Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+972.15 h40.506 days <br />5.787 weeks <br />1.332 months <br />)
Opened:	Randy Crowe 17:09 Dec 29, 2009
NRC Officer:	Donald Norwood
Last Updated:	Dec 29, 2009
45595 - NRC Website
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v t e Emergency Notification System
Lake Norman Regional Medical Center with Agreement State
WEEKMONTHYEAR2009-11-19T05:00:00 [Table view]
[ENS list for Lake Norman Regional Medical Center]

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