ENS 41443

v t e ENS Event
05:00 Feb 24, 2005
Title	Medical Event
Event Description	The following information was provide by the licensee via facsimile: [The Department of Veteran Affairs National Health Physics Program called] per 10 CFR 35.3045 to notify [the NRC] of a possible medical event at the VA Medical Center, Durham, North Carolina, a permittee under the VA license. This event was discovered on February 25, 2005. On February 24, 2005, a permanent-implant prostate brachytherapy procedure was performed at the medical center. 84 Iodine-125 seeds were implanted in the patient. These seeds had around 400 microcuries per seed. A number of seeds were mistakenly placed in fatty tissue, outside of the intended area of treatment. Based on a preliminary evaluation, a possible medical event occurred since the dose to the prostate was possibly more than 20 percent less than that prescribed and a dose to tissue other than the treatment site is possibly more than 50 rem and greater than 50% of the prescribed dose. The authorized user notified the patient and will notify the referring physician within 24-hours of discovery. The National Health Physics Program intends to conduct a reactive inspection next week.

ENS 41443 +/-
Where
Department Of Veterans Affairs Durham, North Carolina (NRC Region 1)
License number:	03-23853-01VA
Organization:	Department Of Veterans Affairs
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+31.3 h1.304 days <br />0.186 weeks <br />0.0429 months <br />)
Opened:	Gary Williams 12:18 Feb 25, 2005
NRC Officer:	Bill Huffman
Last Updated:	Feb 25, 2005
41443 - NRC Website
v • d • e

v t e Emergency Notification System
Department Of Veterans Affairs with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2015-02-24T06:00:00 [Table view]
[ENS list for Department Of Veterans Affairs]

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