ENS Event | |
|---|---|
04:00 Jul 6, 2010 | |
| Title | Agreement State Report - Delivered Dose Different than Prescribed |
| Event Description | The following was received from the State of Georgia via email:
The Licensee reported to the Department [state of Georgia] on July 14, 2010 that a patient who received a prostate seed implant procedure on July 6, 2010 resulted in a medical incident. The patient was scheduled to receive a Cs-131 Isoray seed implantation for the prostate with a total planned activity of 194.3 mCi. During the procedure on July 6, 2010 it was noticed that many of the seeds implanted were not visible on ultrasound. Following final implantation of all the seeds, a cystoscopy was performed on the patient where it was revealed that 19 seeds were implanted in the bladder and not the prostate which was the intended implant site. All 19 seeds were removed from the bladder without difficulty. A post plan evaluation was completed the same day of the treatment. The total activity implanted (seeds implanted to the prostate) was determined to be 140 mCi with a difference of -54.3 mCi deviation from the total planned activity. Post plan D90 for the prostate was calculated to be 62.68% with a D90 deviation of 53.28 Gy from the dose prescribed of 85 Gy. An additional procedure was scheduled for the patient on July 12, 2010 where 18 seeds were implanted to bring the combined dose distribution to the prescribed amount. The department [Georgia Radioactive Materials] reported the incident to NMED in November 2012. Georgia Incident Summary: GA-2010-07i 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. |
| Where | |
|---|---|
| Piedmont Fayette Hospital Fayetteville, Georgia (NRC Region 1) | |
| License number: | GA 1340-1 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+20526.63 h855.276 days <br />122.182 weeks <br />28.117 months <br />) | |
| Opened: | Travis Cartoski 11:38 Nov 7, 2012 |
| NRC Officer: | Pete Snyder |
| Last Updated: | Nov 7, 2012 |
| 48488 - NRC Website | |
Piedmont Fayette Hospital with Agreement State | |
WEEKMONTHYEARENS 581082025-12-10T05:00:00010 December 2025 05:00:00
[Table view]Agreement State Leaking Sealed Source ENS 553862021-07-14T04:00:00014 July 2021 04:00:00 Agreement State Medical Misadministration ENS 484882010-07-06T04:00:0006 July 2010 04:00:00 Agreement State Agreement State Report - Delivered Dose Different than Prescribed 2025-12-10T05:00:00 | |