PNO-I-87-080A, on 870811,NRC Received Rept from Licensee That 11 Ir-192 Seeds Used as Therapeutic Lip & Cheek Implant Lost.Patient Apparently Threw Seeds on Floor.On 870812, Licensee Reported Seeds Recovered from Dumpster
| ML20237H949 | |
| Person / Time | |
|---|---|
| Site: | 03001237 |
| Issue date: | 08/13/1987 |
| From: | Friedman L, Jason White NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| References | |
| PNO-I-87-080A, PNO-I-87-80A, NUDOCS 8708170429 | |
| Download: ML20237H949 (2) | |
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'.S DCS: 03001237870810 Date: August 13, 1987 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE--PNO-I-87-80A This preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information has been confirmed with the licensee by Region I personnel.
Facility: Veterans Administration Licensee Emergency Classification:
Medical Center West Haven, Conn. 06516 Notification of Unusual Event
- 05) Alert (L/N 06q12.5p Site Area Emergency 70- General Emergency X Not Applicable
SUBJECT:
LOSS OF IRIDIUM-192 SEEDS DURING THERAPY PROCEDURE (UPDATE)
On August 11, 1987, NRC Region I received a report from the licensee that 11 iridium-192 seeds encased in a nylon ribbon, with a total activity of 11 millicuries (mci) had been lost. The seeds had been used in an therapeutic implant of a patient's lip and cheek beginning on August 7. The lip implant was removed at about 6:00 p.m. on August 10.
The cheek implant was scheduled to bc removed on August 13. At 6:45 a.m. on August 11,
,the patient told a nurse that he had removed the cheek implant the night before and thrown it on the floor.
The original PN reported that a radiation survey of the facility had been performed by two inspectors from the Connecticut Department of Environmental Protection (DEF), which had been alerted by the licensee. The DEP inspectors had found slightly elevated radiation levels around the dumpster where the licensee's normal trash is collected.
On August 12, 1987, the licensee notified NRC Region I that the seeds had been founo in the dumpster and recovered at approximately 1:30 p.m. that day.
, Region I will review this incident during the next inspection of the West Haven VA l facility to determine the causes of this incident and to evaluate the licensee's I corrective actions.
The State of Connecticut has been notified.
CONTACT: L. Friedman J. White 488-1276 488-1102
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