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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 44853 | 12 February 2009 08:00:00 | 10 CFR 35.3045(a)(1) | Brachytherapy Seeds Misplaced in Patient | A medical event was discovered on February 12, 2009, for a patient treated at the VA Greater Los Angeles Healthcare System, Los Angeles, California. The medical event involved a patient who had undergone permanent implant prostate seed brachytherapy on February 12, 2009, using iodine-125 seeds. Approximately five seeds were mistakenly placed more than one centimeter from the prostate toward the perineum. This treatment result is interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(3). The causes and clinical effects are under review. At this time, it is not believed that the misplaced seeds will cause any adverse deterministic effects to the patient. The permittee is aware of the requirements in 10 CFR 35.3045 regarding notification of the patient and referring physician. A 15-day written report for the medical event will be submitted to NRC Region III. National Health Physics Program will notify the NRC Project Manager, NRC Region III, of the medical event. The permit number for the facility involved in this medical event is VHA Permit No. 04-00181-04. A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient. |