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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 44813 | 27 January 2009 08:00:00 | 10 CFR 35.3045(a)(1) | Medical Event - Actual Dose Less than Prescribed Dose | Two medical events were discovered on January 27, 2009, for patients treated during 2005 at VA Greater Los Angeles Healthcare System, Los Angeles, California. These two medical events involved patients who had undergone permanent implant prostate seed brachytherapy using iodine-125 seeds. The resulting seed distributions in the patients were associated with a D90 dose to the treatment site that was less than 80% of the prescribed dose. These patient circumstances are interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(1)(i). A 15-day written report for the medical events will be submitted to NRC Region III. We have notified our NRC Project Manager (Cassandra Frazier, NRC Region III) of the medical events. 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. | ||
| ENS 41592 | 9 April 2005 06:00:00 | 10 CFR 35.3045(a)(1) | Possible Medical Event | The VA National Health Physics Program (master materials licensee) reported a possible medical event at one of its permittees involving a Co-60 teletherapy device. The possible event occurred at the VA North Texas Health Care System, Dallas, Texas, on the dates of April 9 and 10, 2005. A patient was treated on Saturday and Sunday, April 9 and 10, 2005, for spinal cord compression. The written directive prescribed a dose of 500 cGy in two equal daily fractions. The intent was to give a total dose of about 2900 cGy, with another directive for the remainder of the fractions to be written on April 11, 2005. The treatment time for the fractions on April 9 and 10, 2005, was miscalculated. 330 cGy were administered instead of the prescribed 500 cGy. To avoid too low a dose, an additional fraction of 200 cGy will be given to the patient. This would not have met the definition of a medical event had a single directive, instead of two, been written for the entire treatment series. No adverse effect to the patient from the event is expected. The permittee has notified the referring physician and patient. The licensee will notify the NRC Region III Project Manager (Kevin Null). |