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. |
| 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 | |
Lake Norman Regional Medical Center with Agreement State | |
WEEKMONTHYEARENS 455952009-11-19T05:00:00019 November 2009 05:00:00
[Table view]Agreement State Agreement State Report - Braychytherapy Dose Differed from the Prescribed Dose by More than 20% 2009-11-19T05:00:00 | |