ENS 48992

v t e ENS Event
04:00 Apr 24, 2013
Title	Agreement State Report - Prostate Seed Implant Early Termination
Event Description	A prostate seed implant procedure was terminated after the insertion of 2 needles. Only 5 of 106 intended seeds were implanted (1.55mCi of 32.86mCi). The patient's anatomy (pubic arch) presented interference to the placement of needles/seeds for proper dose distribution. The patient will now be treated with external beam IMRT [intensity modulated radiation therapy] once post implant CT and dose assessment have been performed in approximately 3 weeks. The patient and referring physician have been notified. The facility notified NYS DOH [New York State Department of Health] same day, written report with corrective actions has been received. To prevent recurrence the urologist will verify during planning volume study that there are no anatomical obstructions to needle placement. Report No. NY-13-02 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 48992 +/-
Where
Unspecified New York (NRC Region 1)
License number:	UNSPECIFIED
Organization:	New York State Dept. Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+201.52 h8.397 days <br />1.2 weeks <br />0.276 months <br />)
Opened:	Robert Snyder 13:31 May 2, 2013
NRC Officer:	Pete Snyder
Last Updated:	May 2, 2013
48992 - NRC Website
v • d • e

v t e Emergency Notification System
Unspecified with Agreement State
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