ENS 48930

v t e 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.

ENS 48930 +/-
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
v • d • e

v t e Emergency Notification System
Unspecified with Agreement State
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