ENS 46027
ENS Event | |
|---|---|
05:00 Oct 1, 2006 | |
| Title | Agreement State Report - Found Brachytheraphy Source Previously Lost |
| Event Description | The State of Kansas provided the following information via facsimile:
This event that occurred during the 4th quarter of 2006 at Wesley Medical Center, LLC, was determined during the State of Kansas IMPEP [Integrated Materials Performance Evaluation Program] inspection conducted the week of June 14, 2010, to be reportable under 10CFR2201. An electronic update to the NMED database will follow. Below are details of the event. During an inspection by KDHE [Kansas Department of Health and Environment] of Wesley Medical Center 2/14/2007, a review of the 4th quarter Radiation Safety Committee notes revealed that a brachytherapy source was lost for approximately 45 hours5.208333e-4 days <br />0.0125 hours <br />7.440476e-5 weeks <br />1.71225e-5 months <br />. From the inspector's notes: 'Incident where a Cs-137 brachytherapy source was lost for approximately 45 hours5.208333e-4 days <br />0.0125 hours <br />7.440476e-5 weeks <br />1.71225e-5 months <br /> before being found in the sheets in the laundry room by the RSO [Radiation Safety Officer]. RSO did not make a determination of exposure to the patient based on conservative and worst case scenarios. Incident was not reported to the State.' The RSO notes read: 'We had one recordable event that has been noted in the HNS system. We had one misplaced cesium 137 brachytherapy source. A patient presented for treatment of cervix cancer and we used low-dose Fletcher Suit system where the cesium sources dwell within the patient for 45 hours5.208333e-4 days <br />0.0125 hours <br />7.440476e-5 weeks <br />1.71225e-5 months <br />. The plan was reviewed and the patient was loaded. On the day of removal, one source was missing when the RSO emptied the tandems. Both physicists searched extensively for the source using a Geiger counter. The source was located on the floor in the laundry capture room for women's health. It was determined that the source never reached its destination in the patient, and that it most likely fell into the bed linens during insertion. One environmental service worker spends approximately five minutes per day having an approximate exposure of 1 mRem from that activity. A member of the public would be limited to 100 mRem of exposure per year and the exposure rate would be approximately 1.2 mRem per hour at 3 meters; some of the walls in the room are cinder blocks which provide some shielding. It was suggested that linen be left in the patient's room during their stay to guard against having an incident such as this in the future.' The licensee was issued a citation for failure to report this as a lost source. Update information provided during the week of June 14, 2010 indicated that the source activity was 37 mCi (15 mg Ra equivalent). KS Event No.: KS100006. |
| Where | |
|---|---|
| Wesley Medical Center Wichita, Kansas (NRC Region 4) | |
| License number: | 19-C041-01 |
| Organization: | Kansas Dept Of Health & Environment |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+32556.22 h1,356.509 days <br />193.787 weeks <br />44.596 months <br />) | |
| Opened: | David Whitfill 17:13 Jun 18, 2010 |
| NRC Officer: | Dong Park |
| Last Updated: | Jun 18, 2010 |
| 46027 - NRC Website | |
Wesley Medical Center with Agreement State | |
WEEKMONTHYEARENS 460272006-10-01T05:00:0001 October 2006 05:00:00
[Table view]Agreement State Agreement State Report - Found Brachytheraphy Source Previously Lost 2006-10-01T05:00:00 | |