ENS 43535
ENS Event | |
|---|---|
17:00 Jul 17, 2007 | |
| Title | Agreement State Report - Six Lost Palladium - 103 Seeds |
| Event Description | {{#Wiki_filter:The following information was received via e-mail:
This is notification of an event in Washington State as reported to the WA Department of Health, Office of Radiation Protection. STATUS: Update/Closed Licensee: Swedish Medical Center City and State: Seattle, Washington License Number: WN-M008-1 Type of License: Broad, Medical Date and time of Event: July 17, 2007, about 10 am. Location of Event: First Hill Campus, Operating Room, Seattle WA. ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention): The licensee reported that beginning at 7:30 am on July 17, 2007; they administered 96 of 102 Palladium-103, prostate cancer therapy seeds. The 6 remaining seeds were counted and placed in a glass storage vial. The vial was labeled and put into a leaded storage container and then placed in the procedure room source storage area. At 10 am, it was noted that only a single storage vial was present where two were expected since two cases had been completed by that time. The rooms, waste containers and other items and adjacent areas were searched and surveyed. A survey of the biohazard storage room was also conducted with no readings above background detected at any of the locations. Others involved with the implants searched and were also unable to find the seeds. At 2:30 pm the RSO was notified. Another search and survey with a Ludlum Model 2221 scaler/rate meter using a model 44-3 probe was conducted at that time. An on site search through the trash compactor of approximately � of the total waste in the compactor was also unsuccessful at finding them. The staff reviewed the implant records and determined that 6 seeds were still missing. At 8:50 pm, the RSO stopped the search and declared the seeds lost. At approximately 9:20 pm, the RSO transmitted an electronic notification to Washington DOH regarding the 6 missing prostate seeds. On July 18, 2007, at 8:30 am, the RSO learned the majority of the linens from the previous day's procedure were still on the loading dock. The RSO had the linen carts segregated and conducted a search and survey. The RSO completed this search and did not find the seeds in the linens. The off site laundry facility was contacted. The laundry facility manager indicated that no containers were found and they would be on the lookout for such a container. After reviewing the timeline and interviewing staff regarding the events, the RSO has determined the cause of the event was inattention to detail and human error on the part of the staff responsible for seed count and reconciliation. An analysis of the seed count and reconciliation process indicates that keeping the unused seeds in the procedure room until all cases for the day have been completed may have contributed to this event. The RSO has immediately required that at the completion of each individual procedure the unused seeds are removed from the procedure room and an independent count of the seeds conducted. This is to be performed before the next case occurs to allow immediate survey of the procedure room in the event the seed count cannot be reconciled. The RSO also has stipulated that trained staff must be present for all procedures while seeds are in use. The RSO has scheduled training for July 26, 2007 to review this event with all operating room staff involved with this procedure. The RSO will also review the procedural changes that have occurred as a consequence of this event. Immediately contacting the RSO will also be emphasized to other users of radioactive material at their periodic radiation safety training and to new users during their orientation. The department considered the licensee to have made every reasonable effort to locate the seeds. Therefore the department did not conduct an on-site investigation. Notification Reporting Criteria: WAC 246-221-240 Reports of Stolen, Lost, or Missing Radiation Sources . Isotope and Activity involved: Palladium-103 seeds (six), 1.08 mCi/seed average. Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): No Lost, Stolen or Damaged? (mfg., model, serial number): LOST: Six Palladium-103 therapy seeds (no SN's), TheraSeed model 200 , manufactured by TheraGenics, 1.08 mCi/seed average, total of 6.48 mCi. Disposition/recovery: Irretrievably lost, no recovery expected. Leak test? N/A Vehicle: N/A. Release of activity? Other than the loss of the 6 seeds, none. Activity and pharmaceutical compound intended: N/A Misadministered activity and/or compound received: N/A Device (HDR, etc.) Mfg., Model; computer program: N/A Exposure (intended/actual): consequences: None expected. Was patient or responsible relative notified? No. Was written report provided to patient? No. Was referring physician notified? Yes, on July 18, 2007. Consultant used? No. Washington Report: WA-07-068 THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL 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. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source }} |
| Where | |
|---|---|
| Swedish Medical Center Seattle, Washington (NRC Region 4) | |
| License number: | WN-M008-1 |
| Organization: | Wa Division Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+309.5 h12.896 days <br />1.842 weeks <br />0.424 months <br />) | |
| Opened: | Arden Scroggs 14:30 Jul 30, 2007 |
| NRC Officer: | Joe O'Hara |
| Last Updated: | Jul 30, 2007 |
| 43535 - NRC Website | |
Swedish Medical Center with Agreement State | |
WEEKMONTHYEARENS 569302024-01-19T20:00:00019 January 2024 20:00:00
[Table view]Agreement State Y-90 Microsphere Misadministration ENS 540222019-04-23T07:00:00023 April 2019 07:00:00 Agreement State Washington Agreement State Report - Lost and Found Radioactive Material ENS 538042018-12-19T08:00:00019 December 2018 08:00:00 Agreement State En Revision Imported Date 1/18/2019 ENS 537942018-12-15T07:00:00015 December 2018 07:00:00 Agreement State Agreement State Report - Medical Misadministration ENS 533772018-01-23T18:30:00023 January 2018 18:30:00 Agreement State Agreement State Report - Patient Received Dose Less than Prescribed Dose ENS 435352007-07-17T17:00:00017 July 2007 17:00:00 Agreement State Agreement State Report - Six Lost Palladium - 103 Seeds ENS 415012005-03-17T20:00:00017 March 2005 20:00:00 Agreement State Argeement State Medical Event ENS 410782004-09-24T07:00:00024 September 2004 07:00:00 Agreement State Agreement State Report ENS 403372003-11-17T08:00:00017 November 2003 08:00:00 Agreement State Patient Received an Overdose During a Brachytherapy Procedure 2024-01-19T20:00:00 | |