PNO-I-98-031, on 980721,RSO Notified Region I That Two I-125 Seeds Unaccounted for Following Permanent Seed Implant Into Patient Prostate Gland.Region I Staff Will Followup on Licensee Evaluations & Corrective Action
| ML20236S118 | |
| Person / Time | |
|---|---|
| Site: | 03002976 |
| Issue date: | 07/22/1998 |
| From: | Darden T, Tara Weidner NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| References | |
| PNO-I-98-031, PNO-I-98-31, NUDOCS 9807240136 | |
| Download: ML20236S118 (1) | |
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July 22, 1998 PRELIMINARY i
NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-I-98-031 This preliminary notification constitutes EARLY notice of events of POSSIBLE cnfoty or.public interest significance. The information is as initially rscaived without verification or evaluation, and is basically all that is
.known by Region I* staff in King of Prussia, Pennsylvania on this date.
Facility Licensee Emercency Classification St. Francis Medical Center Notification of Unusual Event St. Francis Medical Center Alert 400 45th St. Site Area Emergency Pittchurgh, Pennsylvania 15201 General Emergency Docksts: 03002976 License No: 37-01072-01 X Not Applicable
Subject:
LOSS OF TWO IODINE 125 SEEDS
'On. July 21, 1998, the Radiation Safety Officer notified Region I that two iodine 125 seeds were unaccounted for, following a permanent seed implant into.a patient's prostate gland. The activity of each seed was approximately 340 microcuries. The licensee stated that 75 seeds were transported to the operating room, where the seeds were autoclaved and 71 essda were loaded into needles in preparation for the procedure. The physicist counted the 71 seeds as they were inserted into the needles.
The coeds were thea implanted into the patient's prostate gland by an cuthorized user. Following the procedure, a urologist removed five seeds that had migrated into the patient's bladder and returned them to the phyaicist. The licensee stated that they expected to see 66 seeds on the patient's radiographs since five of the 71 implanted seeds hat. been recovered from the bladder. However, only 64 seeds were identified on
.the patient's radiographs. With 64 seeds in the patient, and five seeds recovered from the patient, the licensee realized that two seeds were not cccounted for.
When it was discovered that two seeds were missing, the licensee parformed a survey of the operating room, instruments, linens, trash and fiva of the ten individuals who were present during the operation. The rcmaining five people had already left the area. The physicist was able
-toLaurvey two additional staff members; however, the remaining three were not curveyed.
Tha licensee informed the NRC Operations Center on July 22, 1998 and will provide a written report to Region I as required by 10 CFR 20.2201(b).
R gion I staff will followup on licensee evaluations and corrective cction.
The Commonwealth of Pennsylvania has been notified. The Region I Office of1Public Affairs is prepared to respond to media inquiries.
This information is current as of 2:00 p.m. on July 22, 1998.
Contact:
Tara Weidner Teresa Darden (610)337-5272 (610)337-5245 r
9007240136 990722 g\
PNO-I- g C31
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