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The following was received via facsimile:
… The following was received via facsimile:</br>During a prostrate brachytherapy procedure using a Mick applicator and I-125 sources, 41 of 41 sources were implanted into the patient's perineal soft tissue, inferior to the prostrate (resulting in:) 1. Dose was greater than 5 rem effective dose equivalent, and/or 50 rem to an organ or tissue and 2. the total dose delivered differs from the prescribed dose by 20% or more.</br>Explain the effect, if any, on the individual who received the administration: Possible perineal soft tissue fibrosis. The patient is currently without symptoms six weeks following the implant.</br>Additional notes: </br>Licensee's evaluation of why the event occurred: Visualization of the prostrate was difficult on ultrasound due to poor image quality, leading to needle placement inferior to the prostrate. </br>What actions, if any, have been taken or are planned to prevent recurrence: Discontinuation of the procedure if the locations of the needles are not known to relative certainty. </br>The patient and the referring physician were notified (of this event).</br>No follow-up is required.</br>NC Incident Report Number: 09-63</br>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.necessarily result in harm to the patient. +
05:00:00, 19 November 2009 +
45,595 +
17:09:00, 29 December 2009 +
05:00:00, 19 November 2009 +
The following was received via facsimile:
… The following was received via facsimile:</br>During a prostrate brachytherapy procedure using a Mick applicator and I-125 sources, 41 of 41 sources were implanted into the patient's perineal soft tissue, inferior to the prostrate (resulting in:) 1. Dose was greater than 5 rem effective dose equivalent, and/or 50 rem to an organ or tissue and 2. the total dose delivered differs from the prescribed dose by 20% or more.</br>Explain the effect, if any, on the individual who received the administration: Possible perineal soft tissue fibrosis. The patient is currently without symptoms six weeks following the implant.</br>Additional notes: </br>Licensee's evaluation of why the event occurred: Visualization of the prostrate was difficult on ultrasound due to poor image quality, leading to needle placement inferior to the prostrate. </br>What actions, if any, have been taken or are planned to prevent recurrence: Discontinuation of the procedure if the locations of the needles are not known to relative certainty. </br>The patient and the referring physician were notified (of this event).</br>No follow-up is required.</br>NC Incident Report Number: 09-63</br>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.necessarily result in harm to the patient. +
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00:00:00, 29 December 2009 +
Modification date"Modification date" is a predefined property that corresponds to the date of the last modification of a subject and is provided by <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Help:Special_properties">Semantic MediaWiki</a>.
02:10:33, 2 March 2018 +
17:09:00, 29 December 2009 +
40.506 d (972.15 hours, 5.787 weeks, 1.332 months) +
05:00:00, 19 November 2009 +
Agreement State Report - Braychytherapy Dose Differed from the Prescribed Dose by More than 20% +
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