ENS 56552
ENS Event | |
|---|---|
04:00 Apr 21, 2023 | |
| Title | Agreement State - Lost Brachytherapy Source |
| Event Description | The following was received by email from the South Carolina Department of Health and Environmental Control (The Department):
The Department was notified on 05/09/23, that that one (1) Iodine-125 manual brachytherapy sealed source was lost or missing. The sealed source is a Bard Brachytherapy, Inc. Model STM 1251 with an activity of 0.34 mCi (12.58 MBq). The licensee reported that during a prostate seed implant procedure that occurred on 04/21/23, a single seed was possibly lost and remains unaccounted for. The licensee reported that during the procedure, an incorrectly configured strand was identified in the QuickLink device. This strand was ejected into the transfer device then pushed out into the sterile shielded shipping container so that the loose seeds could be counted. When assessing the seeds in the container, it was observed that one of the two I-125 seeds in this strand was missing. The medical physicists used a Geiger-Mueller counter to immediately survey the sterile cart and surrounding areas. The cart, floor, physician hands, nurse hands, and scrubs were all surveyed and no exposure was detected above background. Several other area surveys were also performed after the procedure was completed. The manual brachytherapy sealed source could not be accounted for. Department inspectors were dispatched to the facility on 05/17/23, and were unable to locate the missing sealed source. This event is still under investigation by the South Carolina Department of Health and Environmental Control. SC internal ID number is: SC230011
The following was received by email from the South Carolina Department of Health and Environmental Control (The Department): A 30-day written report was submitted to the Department on 05/15/23 and a revised 30-day written report was submitted to the Department on 05/17/23. The licensee reported no exposure above background to individuals. The lot number of the manual brachytherapy sealed sources involved in the procedure is BBHQ0080, last leak tested 03/21/23. The licensee has also revised and adopted, or plan to adopt new procedures related to manual brachytherapy implant procedures. This event is considered closed. Notified R1DO (Eve), ILTAB, and NMSS Notifications via email. 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 | |
|---|---|
| Medical University Hospital Auth. Charleston, South Carolina (NRC Region 1) | |
| License number: | 081 |
| Organization: | Sc Dept Of Health & Env Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1015.65 h42.319 days <br />6.046 weeks <br />1.391 months <br />) | |
| Opened: | Adam Gause 11:39 Jun 2, 2023 |
| NRC Officer: | Thomas Herrity |
| Last Updated: | Jun 21, 2023 |
| 56552 - NRC Website | |
Medical University Hospital Auth. with Agreement State | |
WEEKMONTHYEARENS 565522023-04-21T04:00:00021 April 2023 04:00:00
[Table view]Agreement State Agreement State - Lost Brachytherapy Source 2023-04-21T04:00:00 | |