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The following is a summary of the informat … The following is a summary of the information provided by the Louisiana Department of Environmental Quality (LA DEQ) via email:</br>The LA DEQ received notification from the licensee's radiation safety officer (RSO) that a prostate cancer patient, who was prescribed boost therapy by implantation of 83 seeds containing 1.26 mCi of Pd-103 each into the prostate, was found to have received the implantation of all seeds into the perineum instead. This was discovered by the licensee's medical physicist at approximately 1738 CST on November 4, 2025. </br>The improper seed implantation was detected as a result of the physicist's analysis of the post-computed tomography (CT) scan. The physicist reported the medical event without delay to the RSO. The RSO reported the medical event in accordance with Louisiana Administrative Code (LAC) 33:XV.712.B.2. at approximately 0825 CST on November 5, 2025. The RSO stated the post-CT scan had been performed on October 27, 2025, at Our Lady of the Lake Regional Medical Center (OLOL), Baton Rouge, LA. Only CT technologists had reviewed the scan on that date and the improper placement of the seeds was not detected at that time. </br>The seed implantation procedure was conducted at OLOL on July 1, 2025. The patient's urologist was present during the implantation procedure. The RSO stated the root cause of the medical event was still under investigation. The two root cause hypotheses are: 1) faulty zeroing of the ultrasound that the oncologist used to guide implantation of seeds into the patient's prostate due to confusion of the balloon and the patients unusually narrow pelvic arch and 2) movement on the part of the patient pushed the balloon partly out, resulting in incorrect seed implantation. No radiation dose to either the patient's bladder or rectum is suspected. The referring physician and patient will be notified of the medical event within the required 24-hour period.</br>Louisiana report ID number: LA2500012</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.
06:00:00, 1 July 2025 +
12:12:00, 5 November 2025 +
06:00:00, 1 July 2025 +
The following is a summary of the informat … The following is a summary of the information provided by the Louisiana Department of Environmental Quality (LA DEQ) via email:</br>The LA DEQ received notification from the licensee's radiation safety officer (RSO) that a prostate cancer patient, who was prescribed boost therapy by implantation of 83 seeds containing 1.26 mCi of Pd-103 each into the prostate, was found to have received the implantation of all seeds into the perineum instead. This was discovered by the licensee's medical physicist at approximately 1738 CST on November 4, 2025. </br>The improper seed implantation was detected as a result of the physicist's analysis of the post-computed tomography (CT) scan. The physicist reported the medical event without delay to the RSO. The RSO reported the medical event in accordance with Louisiana Administrative Code (LAC) 33:XV.712.B.2. at approximately 0825 CST on November 5, 2025. The RSO stated the post-CT scan had been performed on October 27, 2025, at Our Lady of the Lake Regional Medical Center (OLOL), Baton Rouge, LA. Only CT technologists had reviewed the scan on that date and the improper placement of the seeds was not detected at that time. </br>The seed implantation procedure was conducted at OLOL on July 1, 2025. The patient's urologist was present during the implantation procedure. The RSO stated the root cause of the medical event was still under investigation. The two root cause hypotheses are: 1) faulty zeroing of the ultrasound that the oncologist used to guide implantation of seeds into the patient's prostate due to confusion of the balloon and the patients unusually narrow pelvic arch and 2) movement on the part of the patient pushed the balloon partly out, resulting in incorrect seed implantation. No radiation dose to either the patient's bladder or rectum is suspected. The referring physician and patient will be notified of the medical event within the required 24-hour period.</br>Louisiana report ID number: LA2500012</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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LA-2651-L01, Amendment Number 136 +
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127.217 d (3,053.2 hours, 18.174 weeks, 4.182 months) +
06:00:00, 1 July 2025 +
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