ENS Event | |
|---|---|
04:00 Mar 25, 2013 | |
| Title | Agreement State Report - Radioactive Seed Migrated Deeper Into Tissue and Was Not Removed |
| Event Description | The following information was received by facsimile:
A patient for axillary node dissection with radioactive seed localization had an 8.33MBq 123 I [Iodine] seed placed at tumor site under ultrasound guidance by radiologist. The surgeon successfully removed the tumor and lymph node, however the seed had migrated deeper into tissue and was not removed. The surgeon determined that the new seed location prevented safe extraction due to scarring from previous node removal, mastectomy and reconstructive, surgery. NYS DOH [The New York State Department of Health] received verbal notice within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> and written notice within 15 days. The patient, referring physician, medical oncologist, and radiologist have all been notified. A localized dose at 0.5 cm from the seed of 22.9Gy was calculated, negligible dose at 6 cm. As a corrective action the facility will no longer use radioactive seed localization for axillary node lesions. [Licensee] Policy updates and staff notifications are to be evaluated during the next routine inspection. Event Report Identification Number: NY-13-01 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 | |
|---|---|
| Unspecified New York (NRC Region 1) | |
| License number: | UNSPECIFIED |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+537.53 h22.397 days <br />3.2 weeks <br />0.736 months <br />) | |
| Opened: | Robert Snyder 13:32 Apr 16, 2013 |
| NRC Officer: | John Shoemaker |
| Last Updated: | Apr 16, 2013 |
| 48930 - NRC Website | |
Unspecified with Agreement State | |
WEEKMONTHYEARENS 518322016-03-29T04:00:00029 March 2016 04:00:00
[Table view]Agreement State Agreement State Report - Medical Event ENS 495872013-10-30T05:00:00030 October 2013 05:00:00 Agreement State Agreement State Report - Radioactive Seed Incorrectly Placed on Patient ENS 489922013-04-24T04:00:00024 April 2013 04:00:00 Agreement State Agreement State Report - Prostate Seed Implant Early Termination ENS 489302013-03-25T04:00:00025 March 2013 04:00:00 Agreement State Agreement State Report - Radioactive Seed Migrated Deeper Into Tissue and Was Not Removed 2016-03-29T04:00:00 | |