PNO-III-91-027, on 910621,licensee Discovered Ir-192 Brachytherapy Seeds Missing.Licensee Suspects That Missing Seeds Inadvertently Adhered to Dressing Early in Treatment & Deposited in Trash Container.Continuing Investigation
| ML20198C044 | |
| Person / Time | |
|---|---|
| Site: | 03009792 |
| Issue date: | 06/24/1991 |
| From: | Schultz W, Slawinski W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| References | |
| PNO-III-91-027, PNO-III-91-27, NUDOCS 9106280022 | |
| Download: ML20198C044 (1) | |
1Dc o l PRELIMlHARY NOTIFICATTON OF EYFNT OR Uf;USURL OCCURRENCE PN0-III-91-27 Date June 24, 1991
=This preliminary octification constitutes EARLY notice of events of POSSIBLE salety or
. .q d c interest significance. The information is as initially received without t/erification or evaluation, and is basically all that is known by the Region III l staff on this date. [N Facility: University of Cincinnati Licensee Emergency Classification Cincinnati, Ohio General Erergency Site Area Energency Alert Unusual Event N/A X
~ ~ ~ -
License No. 34-06903-05
Subject:
MISSING IRIDIUM-192 BRACHYTHERAPY SEEDS On June 21, 1991, the licensee discovered three iridium-192 brachytherapy seeds totallirt 3.96 millicuries were missing.
The three seeds were among 22 that were surgically irplanted into the head of a atient on June 14. The patient was being treated for a brain tunor. When the seeds p(each about the size of a pencil point) were removed on June 21, the three were discovered missing.
The patient's surgical dressing is changed daily and the used dressing is placed in a trash can _in the patient's room. The licensee suspects that the missing seeds inadvertently adhered to the dressing early :n the treatment and were deposited in the trash container. The trash was apparently collected by a housekeeping staf f member on or about June 17 and thrown into a dumpster, which was taken to a local landfill. The trash was not surveyed by the licensee beforehand. Radiological surveys have been performed of the patient, the patient's room, and other logical areas, including the laundry and trash dumpster. The licensee is continuing its investigation.
Iridium-192 has a half-life of 75 days. Four millicuries of iridium-192 produces radiation levest of about 2 milliren per hour at a distance of one meter.
A Region 11I (Chicago) radiation specialist will visit the hospital June 25 to evaluate this event and determine if it was a medical misacministration. The State of Ohio will be notified. The information in this Prelim' iary Notification has been reviewed with licensee management.
21, 1991. This Region III was information notified is current asofofthis event 11:30 a.m.at(CDT 4 p).m. (CDT),
, June June 24, 1991.
CONTACT: W. Sla U. S tl 388-5618 388-5526 1
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g62jg22c10624 Rev. 10/23/90 ) n l U PNO-1II-p1-027 pgq