ENS 44522
ENS Event | |
|---|---|
05:00 Sep 24, 2008 | |
| Title | Medical Dose Less than 80% of Prescribed Dose |
| Event Description | In response to medical events discovered at the VA Medical Center Philadelphia, which have been reported under Event Number 44219, reviews are ongoing of samples of patient charts from other VA facilities with permanent prostate seed implant brachytherapy programs.
As the result of these ongoing reviews, possible medical events were discovered on September 24, 2008, for 7 patients treated at the VA Medical Center in Jackson, Mississippi. These 7 possible medical events involved seed distributions in the patients that may result in D90 doses less than 80% of the prescribed doses. These circumstances are interpreted as meeting the definition of a medical event under 10 CFR 35.3045. (The D90 is the dose that covers 90% of the volume of the prostate.) The VHA National Health Physics Program will ensure that the medical center follows NRC requirements for notification of the patients. These treatments and their possible effects on the patients are under review by medical experts. A 15-day written report of these 7 possible medical events will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these possible medical events. Additional Information Department of Veterans Affairs has a Master Materials License (MML) from the NRC: License No. 03-23853-01VA. Permits are issued under the MML to VA facilities. The VA submits reports to the NRC through the VHA's National Health Physics Program office located in North Little Rock, AR. Address of permittee involved in this event: VA Medical Center, 1500 East Woodrow Wilson Drive, Jackson, Mississippi 39216. VHA permit number of permittee involved in event: Permit No. 23-08786-01.
This report is an update to Event Report Number 44522. As the result of an ongoing review, an additional possible medical event was discovered on October 7, 2008. This brings the total number of possible medical events to eight (8) under Event Report Number 44522. The circumstances are similar to those previously reported for this event number. A 15-day written report of this additional medical event will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III) of this additional possible medical event. Notified the R3DO (Lara) and FSME (Einberg).
This report is an update to Event No. 44522. An additional medical event was discovered on October 29, 2008, for a patient treated at the VA Medical Center in Jackson, Mississippi. This medical event involved a patient who had undergone permanent implant prostate seed brachytherapy using iodine-125 seeds. The resulting seed distribution in the patient was associated with a D90 dose to the treatment site that was less than 80% of the prescribed dose. The circumstances were interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(1). A total of eight (8) events have been previously reported to the NRC under this event number. This additional event brings the total number of events to nine (9) for this facility. A 15-day written report on this additional medical event will be submitted to NRC Region III. I have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of this additional medical event. Notified R3DO (Kozak) and FSME (Burgess).
This report is an update to Event No. 44522. One additional medical event was discovered on December 16, 2008, for a patient treated at the VA Medical Center, Jackson, Mississippi. This medical event involved a patient who had undergone permanent implant prostate seed brachytherapy using iodine-125 seeds. The resulting seed distribution in the patient was associated with a D90 dose to the treatment site that was less than 80% of the prescribed dose. The circumstances were interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(1). A total of nine (9) events have been previously reported to the NRC under this event number. This additional event brings the total number of events to ten (10) for this facility. A 15-day written report on this additional medical event will be submitted to NRC Region III. We have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of this additional medical event. Notified R3DO (Skokowski) and FSME (Flannery). 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 | |
|---|---|
| Department Of Veterans Affairs Jackson, Mississippi (NRC Region 4) | |
| License number: | 03-23853-01VA |
| Organization: | Va Medical Center Jackson |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+39.2 h1.633 days <br />0.233 weeks <br />0.0537 months <br />) | |
| Opened: | Ed Leidholdt 20:12 Sep 25, 2008 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Dec 17, 2008 |
| 44522 - NRC Website | |
Department Of Veterans Affairs with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 510692015-02-24T06:00:00024 February 2015 06:00:00
[Table view]10 CFR 35.3045(a)(1) Incorrect Dose Recorded on Prescription Directive ENS 508332014-12-29T06:00:00029 December 2014 06:00:00 10 CFR 35.3045(a)(1) Medical Event - Underdose ENS 445222008-09-24T05:00:00024 September 2008 05:00:00 10 CFR 35.3045(a)(1) Medical Dose Less than 80% of Prescribed Dose ENS 432652006-05-31T05:00:00031 May 2006 05:00:00 10 CFR 35.3045(a)(1) Medical Event - Patient Received Dose Greater than Prescribed ENS 414432005-02-24T05:00:00024 February 2005 05:00:00 10 CFR 35.3045(a)(1) Medical Event 2015-02-24T06:00:00 | |