EN Revision Text: AGREEMENT STATE REPORT -
I-125 APPLICATOR LEAK TEST FAILURE
The following was received via e-mail:
During a Wisconsin Department of Health Services inspection a previously unreported event was discovered. The date of the event is still being determined.
While performing a manual brachytherapy procedure, the Mick applicator became jammed and the licensee switched to a different applicator to finish the procedure. Following the procedure, the [Radiation Safety Officer] RSO wiped the jammed device and found contamination so several I-125 seeds were isolated and held for decay in storage."
This indicates that the device failed a leak test, which is a reportable event.
- * * UPDATE ON 05/10/2019 AT 1108 EDT FROM JOSEPH ROSS TO JEFFERY HERRERA * * *
On December 6, 2016, while performing a manual brachytherapy procedure, a Mick applicator became jammed when the oncologist was attempting to insert a seed. The radiation oncologist removed the Mick applicator and switched to an extra Mick applicator with a different cartridge of seeds. A surgeon continued implanting seeds with the physicist to finish the procedure. Meanwhile, the radiation oncologist forcefully extracted the cartridge from the jammed Mick applicator. This was when the physicist/RSO believed that a seed was ruptured. Following the procedure, the RSO took the Mick applicator to the nuclear medicine hot lab and wiped the device and cartridge. The RSO found contamination on the seeds/cartridge so thirteen I-125 seeds (.333mCi each) were isolated and held for decay in storage in the hot lab.
There is no indication of contamination in the operating room surveys or any expected uptake by the patient.
Notified R3DO (Stoedter) and NMSS Events (via email).
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.