ENS Event | |
|---|---|
04:00 Sep 26, 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 26, 2008, for 3 patients treated at the VA Medical Center in Washington DC. These 3 possible medical events involved seed distributions in the patients that may result in D90 doses less than 80% of the prescribed doses. These circumstances may meet 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 will be reviewed by medical experts. A 15-day written report on these 3 possible medical events will be submitted to NRC Region III pursuant to 10 CFR 35.3045. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these possible medical events. The US 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, 50 Irving Street NW, Washington DC 20422. The VHA permit number of the permittee involved in event: Permit No. 08-00942-05."
The licensee is retracting this report based on the following: We are making this notification to retract medical events reported earlier under Event No. 44524. During a reactive inspection, the VA Medical Center in Washington, DC, provided the VHA National Health Physics Program with revised dose information indicating D90 doses were greater than 80% of the prescribed dose for all three patient treatments. We will notify our NRC Project Manager (Cassandra Frazier, Region III) of this retraction. Notified R3DO (Kunowski) and FSME (Burgess). 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 | |
|---|---|
| Va Medical Center Washington Dc Washington, District Of Columbia (NRC Region 1) | |
| License number: | 03-23853-01Va |
| Organization: | Va National Health Physics Program |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+14.25 h0.594 days <br />0.0848 weeks <br />0.0195 months <br />) | |
| Opened: | Ed Leidholdt 18:15 Sep 26, 2008 |
| NRC Officer: | Bill Huffman |
| Last Updated: | Dec 2, 2008 |
| 44524 - NRC Website | |
Va Medical Center Washington Dc with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 445242008-09-26T04:00:00026 September 2008 04:00:00
[Table view]10 CFR 35.3045(a)(1) Medical Dose Less than 80% of Prescribed Dose 2008-09-26T04:00:00 | |