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. |
| 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 | |
Hardin Memorial Hospital with Agreement State | |
WEEKMONTHYEARENS 535852018-09-07T04:00:0007 September 2018 04:00:00
[Table view]Agreement State Agreement State Report - Administered Dose Lower than Prescribed Dose ENS 526112017-02-16T05:00:00016 February 2017 05:00:00 Agreement State Agreement State Report - Administered Dose Lower than Prescribed Dose ENS 509342015-03-25T17:00:00025 March 2015 17:00:00 Agreement State Agreement State Report - Medical Event During Prostate Brachytherapy ENS 491972013-07-16T16:30:00016 July 2013 16:30:00 Agreement State Agreement State Report - Permanent Prostate Brachytherapy Underdose ENS 480862012-06-04T05:00:0004 June 2012 05:00:00 Agreement State Kentucky Agreement State Report - Medical Event Involving Prostate Seed Implants ENS 454852009-08-28T06:00:00028 August 2009 06:00:00 Agreement State Agreement State Report - Brachytherapy Patient Received More than Prescribed Dose 2018-09-07T04:00:00 | |