ENS 49986
ENS Event | |
|---|---|
13:00 Apr 1, 2014 | |
| Title | Agreement State Report - Broken I-125 Seed During Implantation |
| Event Description | The following information was received from the State of Maryland via email:
This is a synopsis of an I-125 seed breaking during an implant procedure at GBMC [Greater Baltimore Medical Center]. We [GMBC] will be meeting as a team to discuss corrective action and how to avoid something like this happening again. An I-125 implant was performed at GBMC Hospital on Tuesday, April 1, 2014. 78 Bard I-125 seeds, activity 0.319 mCi/seed, were ordered for the procedure, 71 seeds were used, and 70 seeds were confirmed after the procedure on CT evaluation in Radiation Oncology. The unused seeds (7.5 seeds) were returned to Radiation Oncology and recorded as per policy and procedure. The chief physicist and dosimetrist were called to Cysto at approximately 0900 EDT when the case was completed to [the attending physician's] satisfaction. Upon entry of the Cysto room [the attending physician] informed the physics staff that a seed had jammed in the Mick applicator and he had to use force to continue and complete the case. On arrival, the physics staff surveyed the patient 1 meter above the umbilicus and found 1.7 mR/hr reading using Model 14C Geiger counter (Serial number 167038, Calibration date 1/30/14). The patient was removed from the OR and sent to recovery room. Upon additional survey of the room, it was discovered that a seed was fractured, when a portion of the seed was found on the sterile table. At that time, a thorough and complete area survey was performed. The reading was found to be 1.2 mR/hour on the table, trash, and blood drain. [A staff member] was called to bring an additional survey meter (Model 3 Geiger counter Serial number 39484, Calibration date 4/29/13). All contaminated items were collected for proper storage in the hot lab in Radiation Oncology. All staff and personnel involved in the case were thoroughly monitored and cleared using 14C Geiger counter (Serial number 167038, Calibration date 1/30/14). After the removal of the contaminated items the Cysto room was thoroughly monitored and clear of radiation contamination. The patient was then brought down to the Radiation Oncology department where a CT scan was performed to ensure seed count. VeriSeed program was used to confirm that the patient was implanted with 70 seeds. [The Chief Medical Physicist] contacted Bard to discuss the shattered seed. It was suggested that radiation oncology staff be monitored for thyroid uptake. Bioassay studies were thereby performed and the results were found to match background readings. On Wednesday, April 2, 2014, the patient's recovery area was scanned using Model 3 Geiger counter Serial number 39484, Calibration date 4/29/13. A reading of 300 CPM was recorded. The background was also recorded to be 300 CPM. |
| Where | |
|---|---|
| Greater Baltimore Medical Center Baltimore, Maryland (NRC Region 1) | |
| License number: | 005-002-03 |
| Organization: | Maryland Dept Of The Environment |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+25.42 h1.059 days <br />0.151 weeks <br />0.0348 months <br />) | |
| Opened: | Alan Jacobson 14:25 Apr 2, 2014 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Apr 2, 2014 |
| 49986 - 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 | |