Event Notification Report for November 04, 2013

MEDICAL EVENT INVOLVING OVEREXPOSURE TO BLADDER DURING PROSTATE TREATMENT

During a prostate cancer treatment, at 1000 hours [CST] on 11/04/13, it was discovered that one I-125 strand with 6 seeds was improperly inserted into the bladder. The patient's prescribed dose was 144 gray to the prostate with a 12% exposure to the bladder. The procedure to the prostate was completed with extra I-125 seeds and the estimated dose to the bladder is 18%. It is believed that shadowing from the urethra, during treatment, was the cause. An attempt to withdraw the seeds from the bladder when the problem was identified was unsuccessful. The patient has been informed and the patient's physician will be informed and will consult with the urologist as soon as possible to determine a method for seed retrieval.

* * * UPDATE ON 11/8/13 AT 1150 EST FROM STEPHEN SLACK TO DONG PARK * * *

The following was received via email:

"The event took place during an implant of I-125 seeds into the prostate of a patient. One strand of six seeds was instead implanted into the bladder. Attempts to remove the strand of seeds at that time were unsuccessful.

"Renewed attempts were made to remove the strand this morning and they were successful. The implant was planned for 144 Gy to the prostate over the full decay time of the I-125. This would have resulted in a mean dose to the bladder of 22.34 Gy. If the extra seeds had remained in place, the mean dose to the bladder would have been 39.15 Gy; hence the report of a Medical Event.

"By removing the seeds this morning, the mean dose to the prostate has been reduced to 23.09 Gy. This is more than 50 rads to the organ but less than a 50% increase over what the organ would have gotten in the planned treatment."

Notified R3DO (Riemer) and FSME Events Resource via email.

* * * UPDATE ON 11/13/13 AT 1757 EST FROM STEPHEN SLACK TO NESTOR MAKRIS * * *

The following was received via email:

The first sentence of the last paragraph in the previous update should have read "By removing the seeds this morning, the mean dose to the bladder has been reduced [to 23.09 Gy]." rather than the mean dose to the prostate.

Notified R3DO (Cameron) and FSME Events Resource via email.

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.

PLANNED MAINTENANCE ON THE PARTICULATE, IODINE, AND NOBLE GAS RADIATION MONITOR

"On November 4, 2013 at 0728 CST, the Kewaunee Power Station rendered the Auxiliary Building SPING [Particulate, Iodine, and Noble Gas] Radiation Monitor Mid and Hi ranges non-functional for planned maintenance. The Emergency Response Organization (ERO) has been notified of the Auxiliary Building SPING non-functionality.

"Work will be performed with high priority on a continuous schedule. The Auxiliary Building SPING is expected to be restored to functional at 1800 CST on November 6, 2013.

"This condition is being reported in accordance with 10CFR50.72(b)(3)(xiii) as an event that results in a major loss of emergency assessment capability (unable to sufficiently identify and classify an Emergency Action Level for off-site radiation conditions). The NRC Resident Inspector has been notified."


* * * UPDATE FROM GARY AHRENS TO DANIEL MILLS AT 1437 EST ON 11/06/13 * * *

The planned maintenance is complete and the Radiation Monitor was returned to service on 11/6/13 at 1010 CST.

The licensee has notified the NRC Resident Inspector.

Notified R3DO (Duncan).