ENS 42150
ENS Event | |
|---|---|
06:00 Nov 17, 2005 | |
| Title | Agreement State Report Involving Loss of Palladium-103 Sources |
| Event Description | On the morning of 11/17/05, Deaconess Health Systems inadvertently discarded a package of twenty-four (24) TheraSeed Palladium-103 Model 200 Implants. Each implant contains a 2.01 mCi Pd-103 source used in the treatment of prostate cancer. The error occurred due to a change in packaging which was not recognized by the recipient. The discarded material was buried at the East Oak Landfill. The licensee does not intend to attempt recovery due to the relatively short half-life, i.e., 17 days, and the small of amount of material involved. The landfill utilizes a portal alarm which did not activate since the material was discarded in it's shielded shipping container.
The State provided the following additional information via facsimile: At approximately 1:00 PM on November 17, 2005 the licensee discovered the loss of 24 Theraseed 200 brachytherapy seeds. Each seed contained 2.01 mCi of Pd-103 at the time of the loss. According to the RSO, the manufacturer of the seeds had recently changed the packaging of the material. Prior to the change, the seeds were all packaged in one lead foil tray. However, the licensee had recently received them packed in three trays stacked one atop another in a single box. In this instance when the box was opened only two trays were removed, the box was discarded with the third tray still inside it. Trash receptacles in the hospital were searched, but the missing materials were not found. The local waste hauler and landfill were contacted and it was determined that the trash had already been delivered to the landfill that morning and had been covered. In light of the short half life of Pd-103 and the low energy of the gamma it emits, and the fact that the sources were still within their shielded tray, it was decided not to attempt to locate them at the landfill. Note also that the name of the licensee on the Oklahoma license is Deaconess Health System, LLC doing business as Deaconess Hospital. Notified R4 DO (J. Clark), NMSS EO (G. Morell) and TAS DO (A. Danis via email) Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. |
| Where | |
|---|---|
| Deaconess Health Systems Oklahoma City, Oklahoma (NRC Region 4) | |
| License number: | OK-21106-01 |
| Organization: | Ok Deq Rad Management |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+10.3 h0.429 days <br />0.0613 weeks <br />0.0141 months <br />) | |
| Opened: | Michael Broderick 16:18 Nov 17, 2005 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Nov 18, 2005 |
| 42150 - NRC Website | |
Deaconess Health Systems with Agreement State | |
WEEKMONTHYEARENS 421502005-11-17T06:00:00017 November 2005 06:00:00
[Table view]Agreement State Agreement State Report Involving Loss of Palladium-103 Sources 2005-11-17T06:00:00 | |