PNO-I-96-056, on 960806,licensee Called NRC Operations Ctr to Rept Loss of Seeds.Licensee Continuing Search & Investigation of Cause of Incident,Including Adequacy of Procedures for Retrieval,Accounting & Inventory
| ML20134B830 | |
| Person / Time | |
|---|---|
| Site: | 03001244 |
| Issue date: | 08/07/1996 |
| From: | Bhalla N, Shanbaky M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20134B832 | List: |
| References | |
| PNO-I-96-056, NUDOCS 9608070308 | |
| Download: ML20134B830 (3) | |
DCS No.:
03001244960806 Date: August 7, 1996 i
PRELIMINARY NOTIFICATION OF EVENT OR UNVSUAL OCCURRENCE PN1-56
)
This preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public interest significance.
The information is as initially received without verification or evaluation, and is basically all that is known by the Region I staff on this date.
Facility:
Yale-New Haven Hospital 20 York Street New Haven, CT 06504 Licensee Emergency Classification:
Notification of Unusual Event Alert Site Area Emergency General Emergency Docket No.:
030-01244 License No.: 06-00819-03 g
ve o tion Code:
H
SUBJECT:
LOSS OF 10 DINE-125 SEEDS At approximately 3:20 pm on August 6,1996, the licensee called the NRC Operations Center to report the loss of 5 iodine-125 sources (seeds), with activity of 0.5 l
nillicuries each. On February 26, 1996 the licensee received 50 iodine-125 seeds, with activity of 3 millicuries each. Of the 50 seeds the licensee used 49 seeds in an eye plaque to treat a patient. On March 6, 1996, the seeds were returned to a vial after i
the seeds were retrieved from the eye plaque. The licensee reported that on March 6, 1996, the seeds were counted and verified to be 50 seeds.
On July 26, 1996 the vial reportedly containing 50 seeds was taken to the operating room to implant the seeds in a patient.
The seeds were placed in a glass dish, the dish covered with a piece of gauze and placed in a stainless steel container, and autoclaved prior to implanting in the patient. The licensee stated that, after the physician implanted 36 seeds in the patient only 9 seeds were left in the vial, versus the expected 14 seeds. The licensee surveyed the operating room, but failed to locate the 5 missing seeds. On a resurvey of the operating room, 3 seeds were found in a blood suction bottle.
The licensee believes that these 3 seeds were dislodged from the 36 seeds that were just implanted into the patient and, therefore, do not account for the 5 missing seeds.
j Seed accountability in the patient could not be verified through X-rays because the patient had an earlier implant of 80 seeds in the same area (oral cavity) and fillings in the teeth obscured some of the seeds in the X-rays.
The licensee believes that either the sources were lost in March 1996, with a total activity at that time of about 15 millicuries, or the sources were lost on July 26, 1996, with a total activity at that time of about 2.5 millicuries.
The licensee is continuing its search and investigation of the cause of this incident, including the adequacy of procedures for retrieval, accounting, inventory, and control of radioactive seeds.
Region I will continue its review of the licensee's performance in this area.
The State of Connecticut has been notified.
Region I is prepared to respond to media inquiries.
Igl
Contact:
Neelam Bhnla Mohamed Shanbaky 0
(610)337-6188 (610)337-5209 (96OSo?O30il)Xer N
HMSS LICENSEE EVENT REPORT License No.
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1.
REPORTING REQUIREMENT
(
0 CFR 20.2201 Theft or loss
()
10 CFR 35.33 Hisadministration
()
10 CFR 20.2203 30 Day Report
() License Condition
()
10 CFR 30.50 Report
() Other 2.
REGION I RESPONSE
()
Immediate Site Inspection Inspector /Date
() Special Inspection Inspector /Date
() Telephone Inquiry Inspector /Date (g)/
v, Preliminary Notification
() Daily Report
(
Information Entered on the Region I Log ya.,
() Review at Next Routine Inspection
() Report Referred to 3.
REPORT EVALUATION
([AescriptionofEvent
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rrective Actions (v(, Levels of RAM Involved
() Calculation Adequate
( ( Cause of Event
() Letter to Licensee Requesting Additional Information 4.
SPECIAL INSTRUCTIONS OR COMMENTS 5 0003 Completed by _. 1 hki w
Date
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Reviewedby(
Date
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