ENS 41718

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v t e ENS Event
05:00 May 18, 2005
Title	Agreement State Report - Unplanned Contamination with Broken Pd-103 Seed (1.7 Millicuries)
Event Description	The State provided the following information via facsimile: On May 18, 2005, during a prostate brachytherapy procedure, a pre-loaded cartridge containing Pd-103 seeds jammed in a Mick applicator. The jam occurred during a cartridge change, and when the authorized user attempted to remove the stuck cartridge from the applicator, the end of one seed was sheared off. After the authorized user reattached the applicator to the needle, he determined a seed had broken. Pieces of the broken seed were found in a needle and in the cartridge. This needle was removed from the patient and a new needle was inserted. The cartridge was removed from the Mick applicator and no contamination was detected on the applicator itself. The patient treatment was completed without further incident. Contamination was detected on several pieces of equipment as well as on the floor of the operating room. All personnel were surveyed before they were permitted to leave the operating room. Access to the operating room was restricted until the room was decontaminated by the radiation safety officer and the medical physicist. The seed fragments and cartridge were placed in a lead pig and secured in the radioactive waste storage area, where they will be held for decay-in-storage. The activity of the broken Pd-103 seed was 1.7 mCi. The licensee notified DHFS on May 18, 2005. The Wisconsin Radiation Protection Section will investigate this event. The State event report number is 26.

ENS 41718 +/-
Where
Gundersen Luthern Medical Center La Crosse, Wisconsin (NRC Region 3)
License number:	063-1121-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+31.57 h1.315 days <br />0.188 weeks <br />0.0432 months <br />)
Opened:	Megan Shober 12:34 May 19, 2005
NRC Officer:	John Knoke
Last Updated:	May 19, 2005
41718 - NRC Website
v • d • e

v t e Emergency Notification System
Gundersen Luthern Medical Center with Agreement State
WEEKMONTHYEAR2005-05-18T05:00:00 [Table view]
[ENS list for Gundersen Luthern Medical Center]

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