Event Notification Report for September 24, 2008
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/23/2008 - 09/24/2008
EVENT NUMBERS
44522
Hospital
Event Number: 44522
Rep Org: VA MEDICAL CENTER JACKSON
Licensee: DEPARTMENT OF VETERANS AFFAIRS
Region: 4
City: JACKSON State: MS
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: ED LEIDHOLDT
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: DEPARTMENT OF VETERANS AFFAIRS
Region: 4
City: JACKSON State: MS
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: ED LEIDHOLDT
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/25/2008
Notification Time: 20:12 [ET]
Event Date: 09/24/2008
Event Time: 00:00 [CDT]
Last Update Date: 12/17/2008
Notification Time: 20:12 [ET]
Event Date: 09/24/2008
Event Time: 00:00 [CDT]
Last Update Date: 12/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
REBECCA TADESSE (FSME)
JAMNES CAMERON (R3)
REBECCA TADESSE (FSME)
JAMNES CAMERON (R3)
MEDICAL DOSE LESS THAN 80% OF PRESCRIBED DOSE
"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 24, 2008, for 7 patients treated at the VA Medical Center in Jackson, Mississippi.
"These 7 possible medical events involved seed distributions in the patients that may result in D90 doses less than 80% of the prescribed doses. These circumstances are interpreted as meeting 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 are under review by medical experts.
"A 15-day written report of these 7 possible medical events will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these possible medical events.
"Additional Information
"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, 1500 East Woodrow Wilson Drive, Jackson, Mississippi 39216.
"VHA permit number of permittee involved in event: Permit No. 23-08786-01."
* * * UPDATE AT 1945 ON 10/8/2008 FROM EDWIN LEIDHOLDT TO MARK ABRAMOVITZ * * *
"This report is an update to Event Report Number 44522. As the result of an ongoing review, an additional possible medical event was discovered on October 7, 2008. This brings the total number of possible medical events to eight (8) under Event Report Number 44522. The circumstances are similar to those previously reported for this event number.
"A 15-day written report of this additional medical event will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III) of this additional possible medical event."
Notified the R3DO (Lara) and FSME (Einberg).
* * * UPDATE AT 1058 EDT ON 10/30/08 FROM HUSTON TO CROUCH * * *
"This report is an update to Event No. 44522. An additional medical event was discovered on October 29, 2008, for a patient treated at the VA Medical Center in Jackson, Mississippi.
"This medical event involved a patient who had undergone permanent implant prostate seed brachytherapy using iodine-125 seeds. The resulting seed distribution in the patient was associated with a D90 dose to the treatment site that was less than 80% of the prescribed dose. The circumstances were interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(1).
"A total of eight (8) events have been previously reported to the NRC under this event number. This additional event brings the total number of events to nine (9) for this facility.
"A 15-day written report on this additional medical event will be submitted to NRC Region III. I have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of this additional medical event."
Notified R3DO (Kozak) and FSME (Burgess).
* * * UPDATE AT 1235 EST ON 12/17/08 FROM HUSTON TO CROUCH * * *
"This report is an update to Event No. 44522. One additional medical event was discovered on December 16, 2008, for a patient treated at the VA Medical Center, Jackson, Mississippi.
"This medical event involved a patient who had undergone permanent implant prostate seed brachytherapy using iodine-125 seeds. The resulting seed distribution in the patient was associated with a D90 dose to the treatment site that was less than 80% of the prescribed dose. The circumstances were interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(1).
"A total of nine (9) events have been previously reported to the NRC under this event number. This additional event brings the total number of events to ten (10) for this facility.
"A 15-day written report on this additional medical event will be submitted to NRC Region III. We have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of this additional medical event."
Notified R3DO (Skokowski) and FSME (Flannery).
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.
"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 24, 2008, for 7 patients treated at the VA Medical Center in Jackson, Mississippi.
"These 7 possible medical events involved seed distributions in the patients that may result in D90 doses less than 80% of the prescribed doses. These circumstances are interpreted as meeting 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 are under review by medical experts.
"A 15-day written report of these 7 possible medical events will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these possible medical events.
"Additional Information
"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, 1500 East Woodrow Wilson Drive, Jackson, Mississippi 39216.
"VHA permit number of permittee involved in event: Permit No. 23-08786-01."
* * * UPDATE AT 1945 ON 10/8/2008 FROM EDWIN LEIDHOLDT TO MARK ABRAMOVITZ * * *
"This report is an update to Event Report Number 44522. As the result of an ongoing review, an additional possible medical event was discovered on October 7, 2008. This brings the total number of possible medical events to eight (8) under Event Report Number 44522. The circumstances are similar to those previously reported for this event number.
"A 15-day written report of this additional medical event will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III) of this additional possible medical event."
Notified the R3DO (Lara) and FSME (Einberg).
* * * UPDATE AT 1058 EDT ON 10/30/08 FROM HUSTON TO CROUCH * * *
"This report is an update to Event No. 44522. An additional medical event was discovered on October 29, 2008, for a patient treated at the VA Medical Center in Jackson, Mississippi.
"This medical event involved a patient who had undergone permanent implant prostate seed brachytherapy using iodine-125 seeds. The resulting seed distribution in the patient was associated with a D90 dose to the treatment site that was less than 80% of the prescribed dose. The circumstances were interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(1).
"A total of eight (8) events have been previously reported to the NRC under this event number. This additional event brings the total number of events to nine (9) for this facility.
"A 15-day written report on this additional medical event will be submitted to NRC Region III. I have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of this additional medical event."
Notified R3DO (Kozak) and FSME (Burgess).
* * * UPDATE AT 1235 EST ON 12/17/08 FROM HUSTON TO CROUCH * * *
"This report is an update to Event No. 44522. One additional medical event was discovered on December 16, 2008, for a patient treated at the VA Medical Center, Jackson, Mississippi.
"This medical event involved a patient who had undergone permanent implant prostate seed brachytherapy using iodine-125 seeds. The resulting seed distribution in the patient was associated with a D90 dose to the treatment site that was less than 80% of the prescribed dose. The circumstances were interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(1).
"A total of nine (9) events have been previously reported to the NRC under this event number. This additional event brings the total number of events to ten (10) for this facility.
"A 15-day written report on this additional medical event will be submitted to NRC Region III. We have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of this additional medical event."
Notified R3DO (Skokowski) and FSME (Flannery).
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.