ENS 54398

v t e ENS Event
18:00 Nov 20, 2019
Title	Agreement State Report - Iodine 125 Seed Migrated from Implant Location
Event Description	The following was received from the State of New York via fax: The New York State Department of Health (NYSDOH) was notified by a NYS medical licensee that they had an incident where an lodine-125 seed (200 microCi assayed on 11/12/2019) had migrated from the original implant location in the left breast of a female patient. According to the licensee, two seeds were implanted on 11/18/2019 for localization during an 11/20/2019 procedure. During this procedure on 11/20/2019, it was noticed by the surgeon that one of the seeds had migrated about 2 inches from its original implant location. The surgeon and radiologist concluded that any attempt to retrieve the seed in question would compromise patient care. The seed was not retrieved as a result. The facility contacted the New York State Department of Health two hours after the licensee determined that the lodine-125 localization seed could not be retrieved from the patient and will be submitting a written report within the required timeframe. DOH will continue to monitor this incident. New York State incident No.: 19-07 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 54398 +/-
Where
Not Provided New York (NRC Region 1)
Organization:	New York State Dept. Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+-1.13 h-0.0471 days <br />-0.00673 weeks <br />-0.00155 months <br />)
Opened:	Daniel Samson 16:52 Nov 20, 2019
NRC Officer:	Thomas Kendzia
Last Updated:	Nov 20, 2019
54398 - NRC Website
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v t e Emergency Notification System
Not Provided with Agreement State
WEEKMONTHYEAR2020-11-23T04:00:00 [Table view]
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