ENS 55655
ENS Event | |
|---|---|
06:00 Mar 17, 2020 | |
| Title | Lost Brachytherapy Seed |
| Event Description | The following information was received from the state of Minnesota via email:
It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO. Mayo Clinic reported the loss of an I-125 localization seed (Best Medical model 2301, lot #49827) that contained an activity of 9.03 MBq (244 microCi). A lesion and the seed were removed from a patient on 3/17/2020. After the lesion was removed from the patient, the surgeon confirmed that the seed was within the specimen with a survey meter. However, the surgeon did not perform a radiograph of the specimen, nor did he inform pathology per procedure that there was a seed to be removed. The seed was noted to be missing by a nuclear medicine technologist on 3/19/2020, which prompted an investigation. All of the remaining lesion tissue was recovered and surveyed, along with the entire pathology laboratory, on 3/20/2020. Mayo Clinic was unable to locate the seed following investigation and determined it was lost. They assumed that the seed was either washed down the sink in the pathology laboratory or incinerated as medical waste. The cause of the incident was concluded to be inadequate training. Corrective actions included developing a new process for selecting a surgeon and radiologist to ensure that qualified personnel are following procedures. Minnesota event number: 200003 THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| Where | |
|---|---|
| Mayo Clinic Rochester, Minnesota (NRC Region 3) | |
| License number: | 1047 |
| Organization: | Minnesota Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+15343.28 h639.303 days <br />91.329 weeks <br />21.017 months <br />) | |
| Opened: | Sherrie Flaherty 14:17 Dec 16, 2021 |
| NRC Officer: | Mike Stafford |
| Last Updated: | Dec 16, 2021 |
| 55655 - NRC Website | |
Mayo Clinic with Agreement State | |
WEEKMONTHYEARENS 566712023-08-09T04:00:0009 August 2023 04:00:00
[Table view]Agreement State Lost Shipment ENS 563332022-12-16T06:00:00016 December 2022 06:00:00 Agreement State Lost Source ENS 561562022-09-28T05:00:00028 September 2022 05:00:00 Agreement State Medical Misadminstration ENS 561372022-09-27T05:00:00027 September 2022 05:00:00 Agreement State Patient Underdose ENS 560102022-07-21T05:00:00021 July 2022 05:00:00 Agreement State Medical Event ENS 553892021-07-29T05:00:00029 July 2021 05:00:00 Agreement State Ageement State Report - Medical Event ENS 552672021-05-18T05:00:00018 May 2021 05:00:00 Agreement State Patient Underdose ENS 556552020-03-17T06:00:00017 March 2020 06:00:00 Agreement State Lost Brachytherapy Seed ENS 533382018-04-13T04:00:00013 April 2018 04:00:00 Agreement State Florida Agreement State Report - Patient Received 65 Percent of Prescribed Dose to Intended Treatment Site ENS 528782017-07-28T04:00:00028 July 2017 04:00:00 Agreement State Agreement State Report - Dose Received Exceeded Prescribed Dose ENS 510252015-04-29T05:00:00029 April 2015 05:00:00 Agreement State Agreement State Report - Medical Underdose ENS 464122010-11-10T17:00:00010 November 2010 17:00:00 Agreement State Agreement State Report - Underdosage to Intended Treatment Area ENS 457882010-03-23T05:00:00023 March 2010 05:00:00 Agreement State Agreement State Report - Improper Dosage Given During Medical Treatment ENS 449492009-03-31T04:00:00031 March 2009 04:00:00 Agreement State Agreement State Report - Lost I-125 Seed 2023-08-09T04:00:00 | |