Two brachytherapy needles (needles 2 and 15) failed to deploy during the brachytherapy implant procedure.The order totaled 20 advantage strands with 67 seeds; the total seeds which were not delivered was nine.The patient was planned to receive 100% of the dose to 43 cc.Due to the inability to implant the two strands containing 9 seeds, the initial implant covered 39.28 cc with 100% of the dose.The patient was sent home and rescheduled to receive a second implant procedure.An additional 20 seeds were ordered by and supplied to the user facility and the rescheduled procedure occurred nine days after (b)(6).The second procedure was performed to complete the original treatment dose prescription.The treatment efficacy was delayed since the patient was subjected to a second procedure to assure a correct treatment dose.A quality assurance investigation is underway.
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