ENS 48671

v t e ENS Event
05:00 Jan 11, 2013
Title	Agreement State Report - Medical Event Involving Prostate Brachytherapy Implant
Event Description	The following information was obtained from the Commonwealth of Pennsylvania Department of Environmental Protection via e-mail: On January 11, 2013 the licensee informed the Department's Southeastern Regional Office of the Medical Event. The event is reportable within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> per 10CFR 35.3045(a)(1)(i). Both the patient and referring physician were notified. On December 4, 2012 the patient received an iodine-125 prostate seed implant. The patient returned for the 30 day post-treatment follow-up CT scan on January 9, 2013. Upon review of the CT results on January 10, 2013, it was discovered that the prostate received approximately 60% of the intended dose. The D90 was determined to be 56 Gy out of a prescribed dose of 110 Gy. The potential cause of the event was noted as possible organ shift or incorrect depth placement of needles. The licensee plans to compensate for the undertreated area with follow-up external beam therapy. They will provide the Department a written report in 15 days. The Southeastern Regional Office plans to follow up with a reactive inspection. 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 48671 +/-
Where
Thomas Jefferson University Hospitals, Inc. Philadelphia, Pennsylvania (NRC Region 1)
License number:	PA-0130
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+81.88 h3.412 days <br />0.487 weeks <br />0.112 months <br />)
Opened:	Joe Melnic 14:53 Jan 14, 2013
NRC Officer:	Ryan Alexander
Last Updated:	Jan 14, 2013
48671 - NRC Website
v • d • e

v t e Emergency Notification System
Thomas Jefferson University Hospitals, Inc. with Agreement State
WEEKMONTHYEAR2013-01-11T05:00:00 [Table view]
[ENS list for Thomas Jefferson University Hospitals, Inc.]

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