ENS 44143
ENS Event | |
|---|---|
19:00 Apr 16, 2008 | |
| Title | Agreement State Report - Medical Event |
| Event Description | A patient at the Oklahoma State University Medical Center in Tulsa, Oklahoma was undergoing prostate treatment. The treatment was to implant 187 Pd-103 seeds (1.5 microCuries each) into the patient. The seeds were injected using a MIC gun which was manufactured by TheraGenics in Buford, Georgia. During the procedure it was observed that one of the seeds was sheared off with only 5% of the seed showing. The patient is believed to have the other 95% of the open seed inside his body. The radiation oncologist was present when this event happened. The patient was surveyed and his radiation levels were 0.46 mr/hr, which is within normal levels. The patient was not informed as yet, but should be by the attending physician. The half life of Pd-103 is 17 days, and most likely will be defused throughout the body.
The State provided the following information via email: At about 2:00 PM on April 16, a patient was receiving 187 Pd-103 seeds for prostate therapy. The seeds were Theragen Model 200 of 1.5 microCuries each, manufactured by Theragenics, in Buford, Georgia, and purchased from Bard in Georgia. After injecting the seeds, the facility discovered one end of a Pd-103 seed in the 'mic' cartridge that had been used to hold the seeds. Only about 5% of the seed was present, and it is assumed the other 95% was injected into the patient. The piece found was leaking radioactivity. Surveys with a calibrated meter showed that the patient met the criteria for unrestricted release. The licensee plans to ask the referring physician to notify the patient. The licensee speculates that a malfunction in the mic gun caused the seed to be out of alignment when the cartridge was inserted or removed, leading to the clipping of the end, but this is highly preliminary, and the result of speculation rather than definite findings. The licensee will do an investigation. The licensee has temporarily stopped doing prostate implants. DEQ will send investigators to the site. Notified FSME (Burgess) and the R4DO (Clark).
The State provided the following information via email: There was a miscommunication between the state and the facilities, average strength for the Pd-103 sources involved in this event is 1.5 milliCuries, rather than 1.5 microCuries. The licensee has informed the patient of the event. The mic gun involved has been taken out of service. It is also considered possible the cartridge holding the sources was flawed, but the cartridges were disposed of as biomedical waste immediately after the surgery and will not be available to be checked. The licensee informs [the state] that the cartridges are generally covered in blood after one of these procedures, and such cartridge disposal is typical. The licensees are holding the mic gun until a state inspector arrives for an investigation, after which it will be returned to the manufacturer for evaluation. Notified FSME (Von Till) and R4DO (Miller). 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 | |
|---|---|
| Oklahoma State University Medical Center Tulsa, Oklahoma (NRC Region 4) | |
| License number: | OK-05860-01 |
| Organization: | Ok Deq Rad Management |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+-2.42 h-0.101 days <br />-0.0144 weeks <br />-0.00331 months <br />) | |
| Opened: | Mike Broderick 16:35 Apr 16, 2008 |
| NRC Officer: | John Knoke |
| Last Updated: | Apr 17, 2008 |
| 44143 - NRC Website | |
Oklahoma State University Medical Center with Agreement State | |
WEEKMONTHYEARENS 441432008-04-16T19:00:00016 April 2008 19:00:00
[Table view]Agreement State Agreement State Report - Medical Event 2008-04-16T19:00:00 | |