ENS Event | |
|---|---|
05:00 Aug 15, 2014 | |
| Title | Agreement State Report - Iodine-125 Seeds Positioned Incorrectly During Implantation |
| Event Description | The following information was received via E-mail:
On August 18, 2014, the licensee notified the Agency [Texas Department of State Health Services] that on August 15, 2014, it discovered that a medical event had occurred. One of the licensee's patients had iodine-125 seed implantation in July 2014 and on August 7, 2014, a post-plan computed tomography scan was performed. During the post-plan evaluation, the licensee discovered that the seeds had not been positioned in the target tissue as prescribed during implantation. The licensee believes that approximately 30 percent of the prescribed dose was delivered to the target tissue. The licensee is evaluating the data to determine actual dosimetrics and will report its calculated dose to the intended and other tissue to the Agency upon completion. The Agency will provide further information in accordance with SA-300. This event occurred at the Baylor All Saints Medical Center in Fort Worth, Texas. Texas Incident #: I-9221 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.
The following was received from the State of Texas via email: The licensee for this event was initially reported as Texas Oncology, license L-05545. It has been determined that Baylor All Saints Medical Center Radiology Department, license L-02212, is the actual licensee the implantation procedure in this event was licensed under. The licensees are continuing their investigation and will submit a written report within the required 15 days. Notified R4DO (Pick) and FSME Events Resource via email. |
| Where | |
|---|---|
| Baylor All Saints Medical Center Fort Worth, Texas (NRC Region 4) | |
| License number: | L-02212 |
| Organization: | Texas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+101.13 h4.214 days <br />0.602 weeks <br />0.139 months <br />) | |
| Opened: | Karen Blanchard 10:08 Aug 19, 2014 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Aug 25, 2014 |
| 50379 - NRC Website | |
Baylor All Saints Medical Center with Agreement State | |
WEEKMONTHYEARENS 503792014-08-15T05:00:00015 August 2014 05:00:00
[Table view]Agreement State Agreement State Report - Iodine-125 Seeds Positioned Incorrectly During Implantation 2014-08-15T05:00:00 | |