ENS 47384

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v t e ENS Event
11:00 Jan 11, 2011
Title	Medical Event - Misadministration of Prostate Cancer Seeds
Event Description	During a recent inspection, an NRC inspector noted two cases which occurred on 8/23/11 and 1/11/11, respectively in which two separate patients were under dosed by greater than 20% during prostate cancer treatment using Iodine 125 seeds. The underdose was determined during post operative treatments. The same physician administered the procedure in both cases. The licensee has informed the prescribing physician, and is investigating the cause of the events. There is no long term permanent functional damage suspected to any organ in either case. The licensee discussed the issue with NRC Region 3 (Gattone). * * UPDATE FROM DENNIS KEHOE TO VINCE KLCO ON 11/01/11 AT 1841 EDT * * * After the licensee reviewed 3 years of medical reports, fourteen patents were found to have been under-dosed greater than 20% of the prescribed dose. Specific under-dose dates were: 4/10/08; 4/21/08; 4/25/08; 9/15/08; 10/17/08; 11/03/08; 2/17/09; 8/27/09; 1/05/10; 1/14/10; 5/25/10; 10/12/10; 5/03/11 and 5/19/11. The licensee discussed the issue with NRC Region 3 (Gattone). Notified the R3DO (Valos) and the FSME EO (Camper). * * RETRACTION FROM DENNIS KEHOE TO VINCE KLCO ON 12/1/2011 AT 1440 EDT * * * The licensee is retracting this event due to the fact that the prostate seed implant for all the above 16 referenced events are planned intra-operatively within the operation. The licensee evaluates the seed implants at the end of the implant operation. Notified the R3DO (Riemer) and FSME (McIntosh). 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 47384 +/- *RETRACTED*
Where
Bay Regional Medical Center Bay City, Michigan (NRC Region 3)
License number:	21-18585-01
Organization:	Jeppesen Radiation Oncology
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+6965.43 h290.226 days <br />41.461 weeks <br />9.541 months <br />)
Opened:	Dennis Kehoe 15:26 Oct 28, 2011
NRC Officer:	Joe O'Hara
Last Updated:	Dec 1, 2011
47384 - NRC Website
v • d • e

v t e Emergency Notification System
Bay Regional Medical Center with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2011-01-11T11:00:00 [Table view]
[ENS list for Bay Regional Medical Center]

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