ENS 42360
ENS Event | |
|---|---|
05:00 Nov 29, 2005 | |
| Title | Agreement State Report Involving a Broken I-125 Brachytherapy Seed |
| Event Description | The following information was received via facsimile:
NY-06-003 Broken I-125 brachytherapy seed. (NYS DOH Internal Tracking No. 421) New York law prohibits the release of any identities in cases of medical events. Therefore the facility name, etc., is not contained in this report. RSO reported a broken I-125 source from a prostate seed implant on 11/29/05. The cartridge/source jammed in the applicator and a source was ruptured. All fragments were recovered in the rinse of the applicator and the patient did not have any seed fragments implanted. The written report stated: 90 seeds were ordered, 74 were implanted, 16 unused seeds were recovered (15 intact, one ruptured). The Mick applicator is a model 200-TP. The seeds were GE Healthcare Medi-physics supplied by Oncura Inc. The apparent activity per seed was 0.47 mCi. The radiation oncologist who performed the procedure is experienced (500+ cases). He stated that during the procedure the applicator jammed several times and that he was required to remove seeds from the applicator. It was probably during that process that the seed was ruptured and the loose seeds fell to the table. The medical physicist, upon going to the operating room to retrieve the unused seeds identified two seeds had become loose, one of which was damaged (appeared shorter than the others). A radiological survey indicated that no contamination was present on instruments or the area used for the implant. The inner contents of the broken seed, a silver rod, were recovered. Measurements indicate that the activity remained with the rod rather than being spread around/causing contamination. Bioassay measurements, thyroid and urine, were performed on the patient, physicist and RSO, all with negative results. All unused seeds were placed into the decay in storage program. This event did not constitute a misadministration because the number of seeds implanted was as per the treatment plan, and there is no evidence that a leaking (ruptured) seed was implanted. New applicators were ordered and placed into service. |
| Where | |
|---|---|
| Not Disclosed By State Law New York (NRC Region 1) | |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+2050.42 h85.434 days <br />12.205 weeks <br />2.809 months <br />) | |
| Opened: | R. Dansereau (Via Fax) 15:25 Feb 22, 2006 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Feb 22, 2006 |
| 42360 - NRC Website | |
Not Disclosed By State Law with Agreement State | |
WEEKMONTHYEARENS 423602005-11-29T05:00:00029 November 2005 05:00:00
[Table view]Agreement State Agreement State Report Involving a Broken I-125 Brachytherapy Seed ENS 423642004-11-05T05:00:0005 November 2004 05:00:00 Agreement State Agreement State Report Involving an I-131 Radiopharmaceutical Misadministration ENS 423632004-09-29T05:00:00029 September 2004 05:00:00 Agreement State Agreement State Report Involving an Intravascular Brachytherapy Event ENS 423622004-05-26T05:00:00026 May 2004 05:00:00 Agreement State Agreement State Report Involving an Intravascular Brachytherapy Event ENS 423592003-12-14T05:00:00014 December 2003 05:00:00 Agreement State Agreement State Report Involving a Medical Misadministration ENS 423582003-04-17T05:00:00017 April 2003 05:00:00 Agreement State Agreement State Report Involving a Radiopharmaceutical Misadministration 2005-11-29T05:00:00 | |