During a prostate cancer treatment, at
1000 hours0.0116 days <br />0.278 hours <br />0.00165 weeks <br />3.805e-4 months <br /> [CST] on 11/04/13, it was discovered that one
I-125 strand with 6 seeds was improperly inserted into the bladder. The patient's prescribed dose was 144 gray to the prostate with a 12% exposure to the bladder. The procedure to the prostate was completed with extra
I-125 seeds and the estimated dose to the bladder is 18%. It is believed that shadowing from the urethra, during treatment, was the cause. An attempt to withdraw the seeds from the bladder when the problem was identified was unsuccessful. The patient has been informed and the patient's physician will be informed and will consult with the urologist as soon as possible to determine a method for seed retrieval.
- * * UPDATE ON 11/8/13 AT 1150 EST FROM STEPHEN SLACK TO DONG PARK * * *
The following was received via email:
The event took place during an implant of I-125 seeds into the prostate of a patient. One strand of six seeds was instead implanted into the bladder. Attempts to remove the strand of seeds at that time were unsuccessful.
Renewed attempts were made to remove the strand this morning and they were successful. The implant was planned for 144 Gy to the prostate over the full decay time of the I-125. This would have resulted in a mean dose to the bladder of 22.34 Gy. If the extra seeds had remained in place, the mean dose to the bladder would have been 39.15 Gy; hence the report of a Medical Event.
By removing the seeds this morning, the mean dose to the prostate has been reduced to 23.09 Gy. This is more than 50 rads to the organ but less than a 50% increase over what the organ would have gotten in the planned treatment.
Notified R3DO (Riemer) and FSME Events Resource via email.
- * * UPDATE ON 11/13/13 AT 1757 EST FROM STEPHEN SLACK TO NESTOR MAKRIS * * *
The following was received via email:
The first sentence of the last paragraph in the previous update should have read "By removing the seeds this morning, the mean dose to the bladder has been reduced [to 23.09 Gy]." rather than the mean dose to the prostate.
Notified R3DO (Cameron) and FSME Events Resource via email.
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.