ENS 43778
ENS Event | |
|---|---|
08:00 Nov 9, 2007 | |
| Title | Agreement State Report - High External Radiation Levels on I-125 Medical Seed Shipment |
| Event Description | The State provided the following information via email:
Bard Brachytherapy, a vendor of I-125 prostate seeds based in Carol Stream Illinois, notified the Illinois Radiation Control Program that they had received a shipment of seeds from a state of Washington licensee, Virginia Mason Medical Center, which had excessive external radiation levels. The Illinois, Division of Nuclear Safety promptly notified the state of Washington, Department of Health via phone and email. At the surface the package was reported to be reading 600 mR/hr while readings at a meter were 1.4 mR/hr. It was determined the lid of the pig which contained the returned seeds (51 seeds total from an original shipment of 90, with an activity of 1406 MBq [38 mCi]) had shifted during transport allowing a beam of radiation to penetrate the external surface of the transport package. Immediately upon notification from Illinois, the shipper (Virginia Mason Medical Center) was contacted. Washington DOH staff spoke with the Authorized Medical Physicist who provided this information: This was the remainder of a shipment originally received by the licensee on 5 November 2007. It arrived with a total of 90, I-125 seeds with an average activity of 0.4 mCi/seed. Thirty-nine of the original 90 seeds were implanted and the remaining 51 were repackaged according to the manufacturer's (Bard's) instructions. At the time of shipment, licensee records show a dose rate at the surface of the package of 0.14 mR/hr, and a reading at one meter of 15 microR/hr. The licensee, upon questioning, acknowledged this shipment differed from all prior shipments from this vendor because it was a sterile shipment (all prior shipments had been non-sterile) and thus came in new/different packaging with different packaging instructions. The licensee firmly believes the lid of the pig was dislodged due to abuse during shipment. The licensee stated they had been in contact with Bard concerning this incident. Bard has agreed that on all future such shipments for clients in the state of Washington (it was unclear if corrective action would be extended to clients in other states as well) Bard will include more tape, for sealing the 'lid' of the pig, and that repackaging shipping instructions would also include steps for taping the pig closed prior to shipment. See also EN #43775, Illinois Agreement State report. |
| Where | |
|---|---|
| Virginia Mason Medical Center Seattle, Washington (NRC Region 4) | |
| License number: | WN-M048-1 |
| Organization: | Wa Division Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+27.75 h1.156 days <br />0.165 weeks <br />0.038 months <br />) | |
| Opened: | Arden Scroggs 11:45 Nov 10, 2007 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Nov 10, 2007 |
| 43778 - NRC Website | |
Virginia Mason Medical Center with Agreement State | |
WEEKMONTHYEARENS 533442018-03-30T07:00:00030 March 2018 07:00:00
[Table view]Agreement State Misadministration of Sir-Spheres Y-90 Microspheres Resulting in an Underdose ENS 521312016-07-27T07:00:00027 July 2016 07:00:00 Agreement State Agreement State Report - Patient Received Less than the Prescribed Dose of I-131 ENS 437782007-11-09T08:00:0009 November 2007 08:00:00 Agreement State Agreement State Report - High External Radiation Levels on I-125 Medical Seed Shipment ENS 430352006-11-29T08:00:00029 November 2006 08:00:00 Agreement State Agreement State Report - Lost Cancer Therapy Seeds 2018-03-30T07:00:00 | |