ENS 44424
ENS Event | |
|---|---|
22:00 Aug 17, 2008 | |
| Title | Agreement State Report - Loss of Ir-192 Seeds |
| Event Description | At 1:30pm on Monday, August 18, 2008, a Maryland Department of the Environment radioactive material licensee, Greater Baltimore Medical Center, reported by phone to MDE RHP a loss of 5 Iridium-192 seeds of 0.59 millicuries each seed. The seeds were in a ribbon implanted in a cancer patient's neck along with 5 other strands of seeds. Numerous checks and plain films were obtained to verify correct location. The seeds had been implanted on Wednesday, August 13, 2008 and were checked daily. The loss of a strand of seeds was discovered on Sunday, August 17, 2008 at approximately 6pm, when the seeds strands were being removed.
Investigative action: The patient was moved to a new room. The licensee reports extensive monitoring of all linens, surfaces, sink drain, other rooms in the unit, nurses station, hallways and the loading dock, where trash was monitored (even though a monitor is located on the loading dock.) A relative's car was also monitored. Being that the patient shaved with a non-electric razor, the outcome of the investigation was that during shaving the strand must have come loose and had fallen into the toilet. The RSO and radiation oncologists and physicists were involved in the investigation. Preventive action is for two radiation workers, (i.e. physician and physicist) to independently check the button crimped on the end of the ribbon strand to insure that the ribbon cannot slide out of the catheter. The written report from the licensee was received by fax on August 19, 2008, at 3:33 pm. Further investigation by MDE RHP is pending. 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. 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. |
| Where | |
|---|---|
| Greater Baltimore Medical Center Baltimore, Maryland (NRC Region 1) | |
| Organization: | Maryland Dept Of The Environment |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+40.82 h1.701 days <br />0.243 weeks <br />0.0559 months <br />) | |
| Opened: | Barbara Park 14:49 Aug 19, 2008 |
| NRC Officer: | John Knoke |
| Last Updated: | Aug 19, 2008 |
| 44424 - NRC Website | |
Greater Baltimore Medical Center with Agreement State | |
WEEKMONTHYEARENS 499862014-04-01T13:00:0001 April 2014 13:00:00
[Table view]Agreement State Agreement State Report - Broken I-125 Seed During Implantation ENS 461432010-07-09T04:00:0009 July 2010 04:00:00 Agreement State Agreement State Report - Patient Exposure to an Unintended Area ENS 444242008-08-17T22:00:00017 August 2008 22:00:00 Agreement State Agreement State Report - Loss of Ir-192 Seeds 2014-04-01T13:00:00 | |