ENS Event | |
|---|---|
05:00 Nov 5, 2019 | |
| Title | Agreement State Report - Medical Event |
| Event Description | The following was received from the Commonwealth of Pennsylvania via email:
The Department [Pennsylvania Department of Environmental Protection] received notification from a licensee on November 6, 2019 that on October 8, 2019 they performed a prostate seed implant on a patient including seventy (70) stranded I-125 seeds that were implanted into the prostate treatment volume. They were Best Medical, Model 2301, Lot 48917, at 0.350 mCi per seed and 24.5 mCi total activity. The patient had an appointment on November 5, 2019 for a 30-day post-plan analysis. The CT from November 5, 2019 noted 2 seeds that were outside the prostate volume in the peri-prostatic fat. The post-plan analysis showed that 68 of 70 seeds are within the treatment volume and 94.4 percent of the treatment volume is covered by the prescription dose, which are within appropriate specifications for a prostate seed implant. The two seeds in question are considered discontiguous from the treatment volume. The licensee believes when the needle was retracted, the strand of seeds drug back with the needle and was deposited inferior from their intended location. An analysis was performed by the licensee and no adverse effects to the patient are expected. Both the patient and referring physician were notified. The Department will update this event as soon as more information is provided. Pennsylvania Event Report ID No: PA190026 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 | |
|---|---|
| Lehigh Valley Health Network Allentown, Pennsylvania (NRC Region 1) | |
| License number: | PA-0232 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+57.13 h2.38 days <br />0.34 weeks <br />0.0783 months <br />) | |
| Opened: | John Chippo 14:08 Nov 7, 2019 |
| NRC Officer: | Brian P. Smith |
| Last Updated: | Nov 7, 2019 |
| 54376 - NRC Website | |
Lehigh Valley Health Network with Agreement State | |
WEEKMONTHYEARENS 543762019-11-05T05:00:0005 November 2019 05:00:00
[Table view]Agreement State En Revision Imported Date 11/20/2019 ENS 470572011-07-12T04:00:00012 July 2011 04:00:00 Agreement State Agreement State Report - Medical Event Involving Treatment Dose Administered to Wrong Site 2019-11-05T05:00:00 | |