ENS 54439: Difference between revisions
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{{ENS notification | {{ENS notification | ||
| event number = 54439 | | event number = 54439 | ||
| facility = | | facility = | ||
| Organization = Florida Bureau Of Radiation Control | | Organization = Florida Bureau Of Radiation Control | ||
| license number = 0155-4 | | license number = 0155-4 | ||
| Line 10: | Line 10: | ||
| utype = | | utype = | ||
| cfr = Agreement State | | cfr = Agreement State | ||
| emergency class = | | emergency class = Non Emergency | ||
| notification date = 12/12/2019 12:26 | | notification date = 12/12/2019 12:26 | ||
| notification by = Reno J Fabii | | notification by = Reno J Fabii | ||
| Line 16: | Line 16: | ||
| event date = 12/11/2019 00:00 EST | | event date = 12/11/2019 00:00 EST | ||
| last update date = 05/28/2020 | | last update date = 05/28/2020 | ||
| title = | | title = Agreement State Report - Dose Delivered Less than Prescribed | ||
| event text = | | event text = The following was received from the Florida Bureau of Radiation Control (the Bureau) via email: | ||
The following was received from the Florida Bureau of Radiation Control (the Bureau) via email: | |||
[The licensee] reported that during a prostate treatment using 50 I-125 seeds, 20 of the seeds became stuck in the applicator and only 30 were inserted into the patient. All of the seeds were accounted for and the patient did not receive any additional exposure or suffer any harm. The remaining treatment dose will be fractionated and delivered at a later time. An additional detailed report containing make, model of seeds, activity, etc. will be forwarded to the Bureau's office later this week. | [The licensee] reported that during a prostate treatment using 50 I-125 seeds, 20 of the seeds became stuck in the applicator and only 30 were inserted into the patient. All of the seeds were accounted for and the patient did not receive any additional exposure or suffer any harm. The remaining treatment dose will be fractionated and delivered at a later time. An additional detailed report containing make, model of seeds, activity, etc. will be forwarded to the Bureau's office later this week. | ||
Incident Number: FL19-146 | Incident Number: FL19-146 | ||
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. | 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. | ||
* * * UPDATE ON MAY 28, 2020 AT 0820 EDT FROM MATT SENISON TO BRIAN LIN * * * | * * * UPDATE ON MAY 28, 2020 AT 0820 EDT FROM MATT SENISON TO BRIAN LIN * * * | ||
The following update was received from the Bureau via email: | The following update was received from the Bureau via email: | ||
[On December 11, 2019], the licensee reported that during a prostate treatment using 50 I-125 seeds, the two Mick applicators suffered jams that could not be cleared. | [On December 11, 2019], the licensee reported that during a prostate treatment using 50 I-125 seeds, the two Mick applicators suffered jams that could not be cleared. After attempts were unsuccessful at restoring function, the user terminated the procedure before the full implant could be completed. Of the 50 Seeds planned for implantation, 30 were successfully inserted into the patient. No I-125 seeds were lost and no spills or contamination occurred. Radiological review of seed placement determined that an adequate number of seeds were placed and dosing achieved in the target area. No further surgical intervention indicated. The patient will be followed with radiological studies and with PSA [prostate specific antigen] labs as previously planned. | ||
Notified R1DO (DeBoer) and NMSS Events Notification via e-mail. | Notified R1DO (DeBoer) and NMSS Events Notification via e-mail. | ||
| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200529en.html#en54439 | | URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200529en.html#en54439 | ||
Latest revision as of 11:36, 15 January 2021
| Where | |
|---|---|
| Florida Bureau Of Radiation Control Jacksonville, Florida (NRC Region 1) | |
| License number: | 0155-4 |
| Organization: | Florida Bureau Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+31.43 h1.31 days <br />0.187 weeks <br />0.0431 months <br />) | |
| Opened: | Reno J Fabii 12:26 Dec 12, 2019 |
| NRC Officer: | Ossy Font |
| Last Updated: | May 28, 2020 |
| 54439 - NRC Website | |