The following information was received from the
Texas Department of State Health Services via E-mail:
On September 11, 2019, the Agency [Texas Department of State Health Services] was notified that the licensee had identified that a medical event had occurred at its facility. The licensee reported it had discovered that the 52 palladium-103 seeds (1.292 mCi each) that had been implanted into a patient on August 1, 2019, which were intended to deliver 100 gray to the prostate, were all inferior to the patient's prostate approximately four centimeters.
The licensee has notified the referring physician and patient. The licensee stated the current plan is to implant the prostate. There are no significant adverse effects expected.
An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300.
- * * UPDATE RECEIVED FROM ART TUCKER TO OSSY FONT ON 09/13/19 AT 1752 EDT * * *
On September 13, 2019, the Agency received additional information on this event. The licensee's report stated that on August 1, 2019, the physician was using ultrasound imaging to locate the prostate [and] misidentified the penile bulb as the prostate. The licensee stated this occurred because the penile bulb was very similar in size (10.8 cc versus 12 cc for the prostate) and they were very close to each other. As a result, 52, 1.292 milliCurie (67.2 milliCurie total) Palladium-103 seeds were placed four centimeters inferior to the prostate. The error was not discovered until September 11, 2019 during the post-implant dosimetry review.
The estimated exposure to 90 percent of the penile bulb is 73 gray. The report stated that the patient is elderly and not sexually active; therefore, there is no increased risk of erectile dysfunction. The licensee identified the urethral structure as additional tissue at risk, but expected the effects to be the same as if the seeds had been properly placed at the prostate. The estimated dose to the prostate was 0 gray. Additional information will be provided as it is received in accordance with SA-300.
Texas Incident No.: I-9710
Notified R4DO (Alexander) and NMSS Events Notification E-mail group.
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.