ENS 52614

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v t e ENS Event
13:00 Mar 16, 2017
Title	Medical Event - Patient Dosage Higher than Prescribed
Event Description	At approximately 0800 CDT today, a patient was treated with 110 Palladium-103 seeds (1.68 milliCuries each) to the prostrate. The quantity was determined by calculation for a prescribed dose of 125 Gy, however the calculation was incorrect. The mistake was discovered after the patient's treatment. Only 80 seeds should have been implanted. The activity injected is 38 percent higher than prescribed. The referring physician has been notified. The physician is notifying the patient. It is believed that this event will not result in any harm to the patient. The licensee is in the process of determining corrective action to prevent reoccurrence. * * UPDATE FROM GREG HAAR TO BETHANY CECERE VIA EMAIL 1241 EDT ON 3/17/17 * * * This email is to confirm our notification to the NRC of a possible medical event that occurred during an LDR [Low Dose Rate] brachytherapy prostate seed implant at our clinic on (3/16/2017) at approximately 0800 [CDT]. The associated license number is #40-34223-01. The procedure was a Palladium-103 implant, with a prescribed dose of 125 Gy. The implant was using Pd-103 seeds with an average activity of 1.68 milliCuries per seed. During this implant, 110 seeds were implanted into the patient instead of 80 seeds. This resulted in a total implanted activity of 184.8 milliCuries, which we estimate to exceed the prescribed dose to the patient by 20 percent. The patient and the referring physician have been notified." Notified R4DO (O'Keefe) and NMSS Events Notification (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.

ENS 52614 +/-
Where
Siouxland Urology Center Dakota Dunes, South Dakota (NRC Region 4)
License number:	40-34223-01
Organization:	Siouxland Urology Center
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+1.47 h0.0613 days <br />0.00875 weeks <br />0.00201 months <br />)
Opened:	Russ Rupolo 14:28 Mar 16, 2017
NRC Officer:	Bethany Cecere
Last Updated:	Mar 17, 2017
52614 - NRC Website
v • d • e

v t e Emergency Notification System
Siouxland Urology Center with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2017-03-16T13:00:00 [Table view]
[ENS list for Siouxland Urology Center]

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