ENS 46958

v t e ENS Event
07:00 Jun 10, 2011
Title	Agreement State Report - Medical Underdose for Prostate Implant
Event Description	The following information was received via e-mail: On Tuesday, June 14, 2011 Mission Hospital notified the Department [California Department of Public Health] that a reportable medical event occurred on June 10, 2011. This event was discovered on June 13, 2011. A patient underwent prostate seed implantation of Pd-103 seeds. Two sets of Pd-103 seeds had been ordered for this patient, and the older set was mistakenly used in surgery. The licensee estimates that this resulted in under treatment of the target organ by 70%. Follow-up information will be provided within 15 days, per 10 CFR 35.3045. This investigation is on-going. California Event: 061411 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 46958 +/-
Where
Mission Hospital Regional Medical Center Mission Viejo, California (NRC Region 4)
License number:	2278-30
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+104.97 h4.374 days <br />0.625 weeks <br />0.144 months <br />)
Opened:	Donald Oesterle 15:58 Jun 14, 2011
NRC Officer:	Mark Abramovitz
Last Updated:	Jun 14, 2011
46958 - NRC Website
v • d • e

v t e Emergency Notification System
Mission Hospital Regional Medical Center with Agreement State
WEEKMONTHYEAR2011-06-10T07:00:00 [Table view]
[ENS list for Mission Hospital Regional Medical Center]

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