ENS Event | |
|---|---|
19:40 May 24, 2007 | |
| Title | Agreement State Report - Pd-103 Source Broken Open |
| Event Description | The State provided the following information via facsimile:
Called to report an incident at Holy Cross Hospital. At 1540 hours0.0178 days <br />0.428 hours <br />0.00255 weeks <br />5.8597e-4 months <br />, on 5/24/07, in room 11 of the operating room of the hospital, the Licensee ruptured a 3.2 mCi Palladium-103 seed while conducting a patient implant therapy. Preliminary licensee evaluation indicates that the Mick Applicator jammed and failed to advance. Efforts to free the device may have led to the seed fracture. The patient therapy was halted after 60 of the 83 seeds (given in the written directive) were successfully implanted. The Oncologist has indicated that the 60 seeds implanted were adequate for successful therapy and no additional seeds would be administered. Licensee followed radiation spill procedures and radiation surveys conducted by licensee RSO showed radioactive material contamination on the Mick Applicator and surrounding absorbent chucks. Contaminated materials have been controlled and stored in nuclear the medicine department. Smears of adjacent OR surfaces and floor were negative for contamination. The OR was released at about 1900 hours0.022 days <br />0.528 hours <br />0.00314 weeks <br />7.2295e-4 months <br /> that day. The licensee has notified the manufacturer of the incident. Licensee will send initial written report by CBD 5/29/07 with follow-up detailed report within 30 days. Maryland Radioactive Material License: MD-31-001-03 A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. |
| Where | |
|---|---|
| Holy Cross Hospital Silver Springs, Maryland (NRC Region 1) | |
| License number: | MD-31-001-03 |
| Organization: | Maryland Dept Of The Environment |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+17.35 h0.723 days <br />0.103 weeks <br />0.0238 months <br />) | |
| Opened: | Ray Manley 13:01 May 25, 2007 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | May 25, 2007 |
| 43390 - NRC Website | |
Holy Cross Hospital with Agreement State | |
WEEKMONTHYEARENS 433902007-05-24T19:40:00024 May 2007 19:40:00
[Table view]Agreement State Agreement State Report - Pd-103 Source Broken Open 2007-05-24T19:40:00 | |