Medical Event Criteria in Prostate Seed Implant / Prostate Brachytherapy

September 15, 2009 · Posted in Misadministration · 1 Comment 

Prostate brachytherapy implant is not going to be perfect all the time. The routine way to check the accuracy of an implant is to obtain a CT scan of the prostate after the implant, then run a post-treatment plan and compare it with the pre-treatment plan. Discrepancy in the delivered dose to the prostate (as well as to the surrounding organs) between the post and pre-plans could create a medical event or misadministration if one or both of the following NRC rules are not met: Read more

NRC: Recent Gamma Knife Misadministration

July 28, 2009 · Posted in Misadministration · Comment 

radiationsymbolOn July 27, 2009, the NRC reported that there has been a medical event at the Gamma Knife Center of the Pacific in Honolulu, Hawaii in which a patient received more than the prescribed dose of gamma radiation to two areas of the brain. Next week, the NRC is conducting a thorough inspection of the medical event, and the full report of the inspection will be available in about 1-2 months.

When the inspection report is completed and issued, it will be interesting to learn the licensee’s root cause and not only what steps were taken by the licensee to prevent such an incident from recurring, but also whether such steps are deemed adequate by the NRC. 

While news of misadministration is always scary and unfortunate, there is always a lesson to be learned by everyone to prevent a similar event from happening at any treatment center.

You can read the official NRC press release here:

A link to the final inspection report as well as a follow-up post will be on this site when the NRC releases the report.

NYT on Prostate Seed Implants

June 26, 2009 · Posted in Misadministration · 1 Comment 

There was an interesting article in the June 20, 2009 issue of the New York Times on Prostate Seed Implants gone wrong at the V.A hospital in Philadelphia. I had expressed concern over the potential inaccuracy of implant placements in a previous article on MDPhysics, but never imagined the degree of error that occurred at this particular brachytherapy program. I cannot fathom how a team of professionals can make such disastrous errors (over and over again). You can read the full article here.

Also, it’s worth mentioning the NYT had a neat graphical “tutorial” on prostate seed implants for the layperson who wanted to know how the procedure is performed. Check it out here.

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