ENS Event | |
|---|---|
04:00 Mar 30, 2014 | |
| Title | Agreement State Report - Iodine 125 Seed Left in Patient |
| Event Description | The following was received from the State of North Carolina via email:
During a recent facility inspection at Duke University Medical Center (License# 0247-4), it was discovered that a lost I-125 seed (National NMED Item #140177) was actually found a couple months later still in the patient's breast tissue. The seed was intended for radioactive seed localization (RSL) of a breast lesion and thought to be excised with the targeted tissue during surgery. Events as follows: -Seed was implanted to patient with 213 uCi on 1/23/2014. -Discovered missing by licensee on 2/27/2014. -Reported lost to NC on 3/21/2014. -Found in patient 3/30/2014, no update given to NC. -Removed from patient breast on 4/1/2014. As of 5/1/2015, the licensee maintains that there was only 12.5 rads received to the 250g of breast tissue and not above the 50 rem for medical event reporting. This is currently under investigation by the NC Radioactive Materials Branch as our preliminary numbers suggest the breast tissue dose could be as high as 66 rem in the maximally exposed 100g of tissue. The licensee is not concerned with overall adverse reaction to the patient health due to them receiving a subsequent external beam radiation treatment that deposited between 300-1100 rads to the affected breast. This possible medical event is tied to the former local NMED Incident# NC 140014 where the source was lost, and it is now being tracked by a new local NMED Incident# NC 150010. 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 | |
|---|---|
| Duke University Medical Center Raleigh, North Carolina (NRC Region 1) | |
| License number: | 0247-4 |
| Organization: | North Carolina Dept Of Hhs |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+9543.17 h397.632 days <br />56.805 weeks <br />13.072 months <br />) | |
| Opened: | David Crowley 19:10 May 1, 2015 |
| NRC Officer: | Daniel Mills |
| Last Updated: | May 1, 2015 |
| 51032 - NRC Website | |
Duke University Medical Center with Agreement State | |
WEEKMONTHYEARENS 562542022-12-01T05:00:0001 December 2022 05:00:00
[Table view]Agreement State Patient Underdose ENS 554092020-08-26T04:00:00026 August 2020 04:00:00 Agreement State Lost IODINE-125 Seed ENS 542822019-09-16T04:00:00016 September 2019 04:00:00 Agreement State Agreement State Report - Medical Event ENS 535912018-09-07T04:00:0007 September 2018 04:00:00 Agreement State Agreement State Report - Administered Dose Lower than Prescribed Dose ENS 525802017-02-24T05:00:00024 February 2017 05:00:00 Agreement State Agreement State Report - Medical Event Due to High Dose ENS 510322014-03-30T04:00:00030 March 2014 04:00:00 Agreement State Agreement State Report - Iodine 125 Seed Left in Patient ENS 463892010-10-22T18:45:00022 October 2010 18:45:00 Agreement State Agreement State Report - Medical Event - Dose Administered in Wrong Location 2022-12-01T05:00:00 | |