ENS 55959
ENS Event | |
|---|---|
16:00 Mar 9, 2021 | |
| Title | Treatment Seeds Released to Public Sewer |
| Event Description | The following was received from the State of South Carolina via email:
On March 10, 2021, the inspector received a telephone message recorded at 7:30 a.m. [EST] from McLeod Regional Medical Center (Lic No. 139) to report an incident that occurred at their facility. The chief medical physicist at the hospital, called to report that at approximately 1:30 p.m., a member of the Day Hospital nursing staff flushed three implant seeds down the toilet into the sanitary sewer. The inspector called to get additional information about the incident. On March 9, 2021, at approximately noon, a patient had prostate seed implantation to act as a boost to the external beam treatment. Following the implantation, the patient passed three Theragenics Model 200 Pd-103 seeds with activity of 1.3 milli-Curie each (3.9 milli-Curie total). On March 12, 2021, the inspector travelled to McLeod Regional Medical Center to talk to the Chief Medical Physicist, Radiation Safety Officer, and other staff to find out additional information about the incident. During the review, the inspector was informed that a nurse did as she was instructed about straining the patient's urine but did not know the next steps once the implant seeds were filtered out. The nurse stated that she was told by another unnamed nurse that they could be flushed. This goes against the procedures that state that a member of health physics is to be informed, and will pick up the seeds once strained. Nursing is supposed to use the available seed recovery kits when a situation like this occurs. Because the toilets flow directly into the public sewer system, the seeds were irretrievable. Additionally, the licensee has procedures in place that state that a urologist will be present to perform a cystoscopy upon the conclusion of the implantation to ensure that there are no seeds in the bladder. This was not performed on the patient before his release to the Day Hospital staff. Both health physics and nursing explained that there has been a high turnover in nursing and that the training should be performed more frequently to ensure compliance from the staff. They are changing the policy to increase the training from annual to at least quarterly to address communication, training, and turnover issues. Day Surgery management stated that they plan to retrain monthly. NMED #210164 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 | |
|---|---|
| Mcleod Regional Medical Center Florence, South Carolina (NRC Region 1) | |
| License number: | 139 |
| Organization: | Sc Dept Of Health & Env Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+11323.65 h471.819 days <br />67.403 weeks <br />15.511 months <br />) | |
| Opened: | Leland Cave 10:39 Jun 24, 2022 |
| NRC Officer: | Thomas Herrity |
| Last Updated: | Jun 24, 2022 |
| 55959 - NRC Website | |
Mcleod Regional Medical Center with Agreement State | |
WEEKMONTHYEARENS 559592021-03-09T16:00:0009 March 2021 16:00:00
[Table view]Agreement State Treatment Seeds Released to Public Sewer ENS 478912012-05-01T19:00:0001 May 2012 19:00:00 Agreement State Agreement State Report - Radioactive Spill During Medical Treatment ENS 455662009-12-09T05:00:0009 December 2009 05:00:00 Agreement State Agreement State Report - Cs-137 Brachytherapy Source Leaking ENS 429352006-05-25T04:00:00025 May 2006 04:00:00 Agreement State Agreement State Report 2021-03-09T16:00:00 | |