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Start date | Reporting criterion | Title | Event description | System | LER | |
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ENS 46958 | 10 June 2011 07:00:00 | Agreement State | Agreement State Report - Medical Underdose for Prostate Implant | The following information was received via e-mail: On Tuesday, June 14, 2011 Mission Hospital notified the Department (California Department of Public Health) that a reportable medical event occurred on June 10, 2011. This event was discovered on June 13, 2011. A patient underwent prostate seed implantation of Pd-103 seeds. Two sets of Pd-103 seeds had been ordered for this patient, and the older set was mistakenly used in surgery. The licensee estimates that this resulted in under treatment of the target organ by 70%. Follow-up information will be provided within 15 days, per 10 CFR 35.3045. This investigation is on-going. California Event: 061411 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. |