ENS 50934

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v t e ENS Event
17:00 Mar 25, 2015
Title	Agreement State Report - Medical Event During Prostate Brachytherapy
Event Description	The following report was received via e-mail: RHB [Kentucky Radiation Health Branch] was notified by telephone on 3/26/15, by the licensee's RSO [Radiation Safety Officer] of a medical event involving an I-125 permanent prostate brachytherapy implant. A CT [computerized tomography] scan performed approximately 5 weeks post-implant revealed that 30% of the implanted activity was administered outside the treatment site (PTV). The delineation of PTV corresponds to a 3 mm margin around the contoured prostate gland, except in the direction of the rectum, prostate base and apex. The error was caused by the inherent difficulty in ultrasound imaging of the prostate, changes in the prostate volume before, during, and after an implant, subjectivity in the contouring of the prostate gland, and a common tendency to drop the seeds slightly inferior to the gland as the needle is retracted. The authorized user reviewed the post plan metrics with the patient and referring physician within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of the discovery of the medical event. The KY RHB [Kentucky Radiation Health Branch] has requested additional information. Kentucky Report #: KY150002 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 50934 +/-
Where
Hardin Memorial Hospital Elizabethtown, Kentucky (NRC Region 1)
License number:	202-148-26
Organization:	Kentucky Dept Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+48.47 h2.02 days <br />0.289 weeks <br />0.0664 months <br />)
Opened:	Marissa Vega Valez 17:28 Mar 27, 2015
NRC Officer:	Mark Abramovitz
Last Updated:	Mar 27, 2015
50934 - NRC Website
v • d • e

v t e Emergency Notification System
Hardin Memorial Hospital with Agreement State
WEEKMONTHYEAR2018-09-07T04:00:00 [Table view]
[ENS list for Hardin Memorial Hospital]

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