ENS 46871

v t e ENS Event
16:00 Apr 4, 2011
Title	Agreement State Report - Medical Event Misadministration of Prostate Seeds
Event Description	The following was received via e-mail: The patient underwent a permanent seed prostate implant in the UCLA 200 Medical Plaza outpatient surgery suite on 4/4/2011. The patient returned to the UCLA Department of Radiation Oncology on 5/3/2011 for a follow-up visit and a post-implant CT scan. A post-implant treatment plan was performed to verify seed placement and final dosimetry endpoints. The post-implant dosimetry plan indicated a significant number of seeds were implanted outside of the prostate. A detailed dosimetry analysis is being performed but is unavailable at the time of this report. This report will provide the details of the intended dose versus the received dose, as well as other supplemental information. This report will be included in the final investigation packet. UCLA has notified CDPH RHB [California Department of Public Health Radiologic Health Branch] that the permanent seed implant program has been placed on temporary hold pending review of this procedure. No further procedures have been performed since this discovery. This investigation is ongoing. CA Report Number: 052011 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 46871 +/-
Where
University Of California Los Angeles Los Angeles, California (NRC Region 4)
License number:	1335-19
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+1128.55 h47.023 days <br />6.718 weeks <br />1.546 months <br />)
Opened:	Donald Oesterle 16:33 May 21, 2011
NRC Officer:	Joe O'Hara
Last Updated:	May 21, 2011
46871 - NRC Website
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v t e Emergency Notification System
University Of California Los Angeles with Agreement State
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