ENS Event | |
|---|---|
06:00 Jul 1, 2025 | |
| Title | Medical Event |
| Event Description | The following is a summary of the information provided by the Louisiana Department of Environmental Quality (LA DEQ) via email:
The LA DEQ received notification from the licensee's radiation safety officer (RSO) that a prostate cancer patient, who was prescribed boost therapy by implantation of 83 seeds containing 1.26 mCi of Pd-103 each into the prostate, was found to have received the implantation of all seeds into the perineum instead. This was discovered by the licensee's medical physicist at approximately 1738 CST on November 4, 2025. The improper seed implantation was detected as a result of the physicist's analysis of the post-computed tomography (CT) scan. The physicist reported the medical event without delay to the RSO. The RSO reported the medical event in accordance with Louisiana Administrative Code (LAC) 33:XV.712.B.2. at approximately 0825 CST on November 5, 2025. The RSO stated the post-CT scan had been performed on October 27, 2025, at Our Lady of the Lake Regional Medical Center (OLOL), Baton Rouge, LA. Only CT technologists had reviewed the scan on that date and the improper placement of the seeds was not detected at that time. The seed implantation procedure was conducted at OLOL on July 1, 2025. The patient's urologist was present during the implantation procedure. The RSO stated the root cause of the medical event was still under investigation. The two root cause hypotheses are: 1) faulty zeroing of the ultrasound that the oncologist used to guide implantation of seeds into the patient's prostate due to confusion of the balloon and the patients unusually narrow pelvic arch and 2) movement on the part of the patient pushed the balloon partly out, resulting in incorrect seed implantation. No radiation dose to either the patient's bladder or rectum is suspected. The referring physician and patient will be notified of the medical event within the required 24-hour period. Louisiana report ID number: LA2500012 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 | |
|---|---|
| Mary Bird Perkins Cancer Center Baton Rouge, Louisiana (NRC Region 4) | |
| License number: | LA-2651-L01, Amendment Number 136 |
| Organization: | Louisiana Radiation Protection Div |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+3053.2 h127.217 days <br />18.174 weeks <br />4.182 months <br />) | |
| Opened: | Russell Clark 12:12 Nov 5, 2025 |
| NRC Officer: | Ernest West |
| Last Updated: | Nov 5, 2025 |
| 58024 - NRC Website | |
Mary Bird Perkins Cancer Center with Agreement State | |
WEEKMONTHYEARENS 580242025-07-01T06:00:0001 July 2025 06:00:00
[Table view]Some use of "" in your query was not closed by a matching "".Agreement State Medical Event ENS 458762010-03-15T12:30:00015 March 2010 12:30:00 Agreement State Radiation Underdose at Prescribed Location ENS 447882008-12-23T06:00:00023 December 2008 06:00:00 Agreement State Agreement State - Medical Misadministration ENS 422632005-11-22T06:00:00022 November 2005 06:00:00 Agreement State Agreement State Report - Medical Event 2025-07-01T06:00:00 | |