ENS 49587

v t e ENS Event
05:00 Oct 30, 2013
Title	Agreement State Report - Radioactive Seed Incorrectly Placed on Patient
Event Description	The following information was received by facsimile: Reported to NYS DOH [New York State Department of Health] on 11/12/2013. A patient received two seeds for right breast radioactive seed localization when only one was intended. The patient had two marker clips, a cylinder clip marking a benign biopsy site and a coil clip marking a papilloma. It was intended for her to only receive one seed placed at the papilloma site, but the benign site was marked with a 0.252 mCi iodine-125 seed. A second seed (0.251 mCi) was then placed to mark the correct site. The unintended dose from the 0.252 mCi seed in place for 2 days was 0.61 Gy @ 0.5 cm. Root cause analysis is ongoing. Event Report Identification Number: NY-13-06 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 49587 +/-
Where
Unspecified New York (NRC Region 1)
Organization:	New York State Dept. Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+676.97 h28.207 days <br />4.03 weeks <br />0.927 months <br />)
Opened:	Robert Snyder 10:58 Nov 27, 2013
NRC Officer:	Dong Park
Last Updated:	Nov 27, 2013
49587 - NRC Website
v • d • e

v t e Emergency Notification System
Unspecified with Agreement State
WEEKMONTHYEAR2016-03-29T04:00:00 [Table view]
[ENS list for Unspecified]

Navigation menu