ENS 54439
ENS Event | |
|---|---|
05:00 Dec 11, 2019 | |
| Title | Agreement State Report - Dose Delivered Less than Prescribed |
| Event Description | The following was received from the Florida Bureau of Radiation Control (the Bureau) via email:
[The licensee] reported that during a prostate treatment using 50 I-125 seeds, 20 of the seeds became stuck in the applicator and only 30 were inserted into the patient. All of the seeds were accounted for and the patient did not receive any additional exposure or suffer any harm. The remaining treatment dose will be fractionated and delivered at a later time. An additional detailed report containing make, model of seeds, activity, etc. will be forwarded to the Bureau's office later this week. Incident Number: FL19-146 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.
The following update was received from the Bureau via email: [On December 11, 2019], the licensee reported that during a prostate treatment using 50 I-125 seeds, the two Mick applicators suffered jams that could not be cleared. After attempts were unsuccessful at restoring function, the user terminated the procedure before the full implant could be completed. Of the 50 Seeds planned for implantation, 30 were successfully inserted into the patient. No I-125 seeds were lost and no spills or contamination occurred. Radiological review of seed placement determined that an adequate number of seeds were placed and dosing achieved in the target area. No further surgical intervention indicated. The patient will be followed with radiological studies and with PSA [prostate specific antigen] labs as previously planned. Notified R1DO (DeBoer) and NMSS Events Notification via e-mail. |
| Where | |
|---|---|
| Florida Bureau Of Radiation Control Jacksonville, Florida (NRC Region 1) | |
| License number: | 0155-4 |
| Organization: | Florida Bureau Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+31.43 h1.31 days <br />0.187 weeks <br />0.0431 months <br />) | |
| Opened: | Reno J Fabii 12:26 Dec 12, 2019 |
| NRC Officer: | Ossy Font |
| Last Updated: | May 28, 2020 |
| 54439 - NRC Website | |
Florida Bureau of Radiation Control with Agreement State | |||||
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