On November 16, 2012, the Agency [Texas Department of State Health Services] was notified by the licensee that a potential medical event occurred. On January 5, 2012, a patient received an
Iodine-125 prostate seed implant of 63 seeds (0.475 mCi/seed). The implant was completed as planned and verification films were taken and confirmed that the implant appeared normal and no concerns were expressed during or immediately after the implant procedure. In late August or early September, a post plan was created for evaluation. 63 seeds were localized by a staff physicist and sometime after or during the post plan analysis, the staff physicist noticed the seed placement appeared inconsistent with the pre-plan. The staff physicist informally notified the Chief Physicist and a Senior Radiation Oncologist who each viewed the plan and concluded that further evaluation was needed. The implant appeared shifted inferior to the prostate. The final determination is that all of the parameters of the implant (activity per seed, total activity, seed distribution, etc.) were all consistent with the pre-plan except that the center of the seed distribution and the center of the prostate were separated by a couple of centimeters and the most inferior seed was approximately 3.5 cm inferior to the apex of the prostate. The licensee has been contacted to report prescribed dose, actual dose, and percent of dose received. Additional information will be provided
IAW SA-300.
Texas Incident# I-9014
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.