Event Notification Report for January 08, 2007
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/07/2007 - 01/08/2007
EVENT NUMBERS
43082
Hospital
Event Number: 43082
Rep Org: HACKLEY HOSPITAL
Licensee: HACKLEY HOSPITAL
Region: 3
City: MUSKEGON State: MI
County:
License #: 21-04125-01
Agreement: N
Docket:
NRC Notified By: CARLO SANTA ANA
HQ OPS Officer: JEFF ROTTON
Licensee: HACKLEY HOSPITAL
Region: 3
City: MUSKEGON State: MI
County:
License #: 21-04125-01
Agreement: N
Docket:
NRC Notified By: CARLO SANTA ANA
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/08/2007
Notification Time: 15:26 [ET]
Event Date: 01/08/2007
Event Time: 10:30 [EST]
Last Update Date: 01/08/2007
Notification Time: 15:26 [ET]
Event Date: 01/08/2007
Event Time: 10:30 [EST]
Last Update Date: 01/08/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE 35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE 35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
THOMAS KOZAK (R3)
GREG MORELL (NMSS)
THOMAS KOZAK (R3)
GREG MORELL (NMSS)
MEDICAL EVENT UNDER DOSE TO INTENDED ORGAN DUE TO IMPROPER SEED IMPLANT
During a seed implant procedure for treating prostate cancer with I-125 (41 seeds with 0.32 millicuries each), the patient moved after inserting 2 of the 14 treatment needles. The procedure was delayed for five minutes to allow the patient to be more completely under general anesthesia. The lineup was checked using ultrasound and once the urologist, the radiation oncologist, and the medical physicist were comfortable with the situation, the seed implant was resumed. Once the procedure was completed, the hospital personnel took a film shot to verify the needle placement. It was discovered that the 12 of 14 remaining needles that were inserted were not in the intended location.
The patient has been notified of the error. The hospital is in the process of determining the prostate underdose and the overdose to the unintended areas (rectal and urethra). The hospital is still evaluating any patient intervention that needs to be identified and if there is any unintended permanent functional damage to other organs.
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.
During a seed implant procedure for treating prostate cancer with I-125 (41 seeds with 0.32 millicuries each), the patient moved after inserting 2 of the 14 treatment needles. The procedure was delayed for five minutes to allow the patient to be more completely under general anesthesia. The lineup was checked using ultrasound and once the urologist, the radiation oncologist, and the medical physicist were comfortable with the situation, the seed implant was resumed. Once the procedure was completed, the hospital personnel took a film shot to verify the needle placement. It was discovered that the 12 of 14 remaining needles that were inserted were not in the intended location.
The patient has been notified of the error. The hospital is in the process of determining the prostate underdose and the overdose to the unintended areas (rectal and urethra). The hospital is still evaluating any patient intervention that needs to be identified and if there is any unintended permanent functional damage to other organs.
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.