ENS 54969

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v t e ENS Event
16:00 Oct 28, 2020
Title	Iodine-125 Seed Inadvertently Left in Patient
Event Description	The following is a summary of a call with the licensee: On October 28, 2020, during a routine mammogram, the radiologist found an I-125 seed in the left axilla that was believed to have been previously removed. The 250 microCi seed was implanted on July 5, 2019 as part of a 10 CFR 35.1000 lesion location procedure. It was supposed to have been removed the same day during removal of the lesion. On the follow-up x-ray of the lesion, the seed was not identified. The radiologist called the operating room, which stated and documented that they had recovered the seed. The licensee noted that there was a second seed implanted in the left breast that was recovered. Both seeds are documented on the same paperwork. An investigation is in progress, but the licensee believes that the dose to the patient is more than 50 rem to the tissue and total dose delivered differs from the prescribed dose by 20 percent or more. The patient was informed and no effects are expected. The licensee will notify the NRC Region 3 Office. * * RETRACTION FROM EVAN BOOTE TO DONALD NORWOOD AT 1620 EST ON 12/2/2020 * * * The following information was received via E-mail: Following review of the images and discussion of this case with surgery [personnel], the linear metallic foreign body previously reported as a 'seed' has a high probability of being a vascular surgical clip. Notified R3DO (Dickson) and NMSS Events Notification E-mail group. 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 54969 +/- *RETRACTED*
Where
Spectrum Health Grand Rapids, Michigan (NRC Region 3)
License number:	210024306
Organization:	Spectrum Health
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+0.83 h0.0346 days <br />0.00494 weeks <br />0.00114 months <br />)
Opened:	Evan Boote 16:50 Oct 28, 2020
NRC Officer:	Ossy Font
Last Updated:	Dec 2, 2020
54969 - NRC Website
v • d • e

v t e Emergency Notification System
Spectrum Health with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2020-10-28T16:00:00 [Table view]
[ENS list for Spectrum Health]

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