ENS 54763
ENS Event | |
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04:00 Jul 1, 2020 | |
Title | Agreement State Report - Medical Event |
Event Description | The following was received via email:
A 98 microCurie I-125 breast cancer localization seed (titanium encapsulated) was inadvertently cut in half during its extraction from a patient. All portions of seed presumably removed and lavage performed. A pancake probe was used at tissue surface prior to tissue closure and measured 200 microR/hr. Tissue entry point was closed and re-surveyed at some later time with a measurement of 10 microR/hr. Post recovery, patient was apprised of the event and initiated a 10-day KI treatment plan. [The Radiation Safety Regional Health Director] is in consultation with the dose calibrator manufacturer and seed manufacturer (Team Best) in order to better calculate activity of recovered seed portions and subsequently compare to initial, inserted activity. The difference will yield activity remaining in the patient. Florida Incident Number: FL20-073 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 | |
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Florida Bureau Of Radiation Control Weston, Florida (NRC Region 1) | |
License number: | 3871-1 |
Organization: | Florida Bureau Of Radiation Control |
Reporting | |
Agreement State | |
Time - Person (Reporting Time:+127.67 h5.32 days <br />0.76 weeks <br />0.175 months <br />) | |
Opened: | David Pieski 11:40 Jul 6, 2020 |
NRC Officer: | Brian P. Smith |
Last Updated: | Jul 6, 2020 |
54763 - NRC Website | |
Florida Bureau of Radiation Control with Agreement State | |||||
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