ENS Event | |
|---|---|
05:00 Jan 23, 2004 | |
| Title | High Background Readings Found in Sterilization Water Used to Sterilize the Seeds and Cartridge Prior to Usage. |
| Event Description | The licensee reported that during the completion of a prostate implant a higher than background reading was measured in the sterilization water used to sterilize the seeds and the cartridge prior to the implant. The licensee had two extra seeds left over after the implant, so they returned them to the manufacturer along with a sample of the sterilization water to be analyzed. The manufacturer suspects that one of the seeds may have been a leaking, but that has not yet been verified. A bioassay was also performed on the staff involved with the implant and only the physicist had a higher than background reading. The patient was also given a bioassay, but since they have never done this to a patient, there was no data to compare with.
The licensee reported that a second patient also had a higher thyroid bioassay but his urine sample tested negative. The licensee is continuing with their investigation. Notified NMSS (Psyk) and R1DO (Kinneman)
Detectable contamination was found upon surveying the left over seeds (12 to 18) from the second patient. Two swipes were taken of all seeds together and the first swipe indicated 809 counts per minute and the second swipe indicated 1689 counts per minute. Background readings was 4 counts per minute. The contamination was localized to the cartridges and seeds. The appropriate areas of the Hospital were surveyed and no detectable contamination was found. The licensee intends to keep the leaking iodine seeds in storage for decay and future disposal. Notified NMSS (Hickey) and R1DO (Kinneman) |
| Where | |
|---|---|
| Mercy Health System Darby, Pennsylvania (NRC Region 1) | |
| License number: | 37-00993-05 |
| Organization: | Mercy Health System |
| Reporting | |
| Information Only | |
| Time - Person (Reporting Time:+273.08 h11.378 days <br />1.625 weeks <br />0.374 months <br />) | |
| Opened: | John Babu 14:05 Feb 3, 2004 |
| NRC Officer: | Chauncey Gould |
| Last Updated: | Feb 6, 2004 |
| 40502 - NRC Website | |
Mercy Health System with Information Only | |
WEEKMONTHYEARENS 405022004-01-23T05:00:00023 January 2004 05:00:00
[Table view]Information Only High Background Readings Found in Sterilization Water Used to Sterilize the Seeds and Cartridge Prior to Usage. 2004-01-23T05:00:00 | |