ENS 54510

v t e ENS Event
05:00 Jan 29, 2020
Title	Agreement State Report - Incorrect Organ Received Treatment
Event Description	The following was received from the South Carolina Department of Health and Environmental Control via email: The South Carolina Department of Health and Environmental Control was notified on 02/03/2020 of a potential medical event involving a prostate seed implant. The procedure occurred on 01/29/2020, and the licensee's radiation safety officer was notified of the potential medical event on 02/03/2020. The prescribed dose to the prostate was 145 Gray, with 76 seeds being implanted. Total activity of the seeds is being reported as 26.6 milliCuries. The licensee is reporting that the seeds were implanted into the bladder and not the prostate. As of 01/31/2020, 41 seeds of the implanted 76 seeds were still implanted in the patient. The licensee is also reporting the loss of 35 seeds. The prostate seed manufacturer is ISOAID, LLC ADVANTAGE I-125. The model of the seeds is IAI-125A. This event is still under investigation by the licensee and the South Carolina Department of Health and Environmental Control. 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. Notified R1DO (Henrion) and NMSS Events (email)

ENS 54510 +/-
Where
Sc Dept Of Health & Env Control Columbia, South Carolina (NRC Region 1)
License number:	076
Organization:	Sc Dept Of Health & Env Control
Reporting

Agreement State
Time - Person (Reporting Time:+128.7 h5.363 days <br />0.766 weeks <br />0.176 months <br />)
Opened:	Adam Gause 13:42 Feb 3, 2020
NRC Officer:	Kerby Scales
Last Updated:	Feb 3, 2020
54510 - NRC Website
v • d • e

v t e Emergency Notification System
South Carolina Department of Health and Environmental Control with Agreement State
WEEKMONTHYEAR2020-08-10T21:30:00 [Table view]
[ENS list for South Carolina Department of Health and Environmental Control]

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