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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 49530 | 12 November 2013 05:00:00 | Agreement State | Agreement State Report - Access Restricted Due to Technetium-99 Spill | The following information was obtained from the Commonwealth of Massachusetts via email: On 11/12/13, licensee reported 10 mCi spill of medical Tc-99m (6-hour half-life) liquid during patient administration. Report based on the licensee's need to restrict access to the area of the spill for more than 24 hours. Licensee reported there was no occupational exposure to workers. Spill cleanup action was performed by licensee but enough residual contamination remained for licensee to restrict access to contaminated room until 10 half-lives (approximately three days) of radioactive decay have passed. Licensee will submit written follow-up report within 30 days. The Agency (Massachusetts Radiation Control Program) considers this matter to be OPEN pending results of ongoing investigation.
The Agency (Massachusetts Radiation Control Program) agrees with recent USNRC determination that this is not a reportable event, because it meets one but not all three of the requirements contained in 105 CMR 120.142 (B)(1) or 10 CFR 30.50 (b)(1). Notified R1DO (Bower) and FSME Events Resource via email. | ||
| ENS 43908 | 15 January 2008 05:00:00 | Agreement State | Massachusetts Agreement State Report - Missing Brachytherapy Seeds | The Licensee's RSO reports that a total of five (5) I-125 brachytherapy seeds, each containing 0.395 millicuries (assayed January 15, 2008) (total activity of 1.975 millicuries) are missing. The Licensee's RSO reports that the seeds were likely lost during or after a procedure performed in the Licensee's operating room on January 15, 2008. The seeds were discovered to be missing on January 16, 2008 and the seeds likely were disposed of in regular trash. The Licensee's RSO reports that the missing seeds are Oncura Echo seed Model 6733 seeds. The Licensee continues to search and survey for the seeds. 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. | ||
| ENS 41143 | 31 August 2004 04:00:00 | Agreement State | Agreement State Report of Medical Misadministration | Patient scheduled to receive template-guided transperineal prostate interstitial brachytherapy for clinical localized prostate cancer was to receive 72 I-125 seeds, instead received 47 seeds resulting in underexposure of greater than 20%. The cartridges carrying 15 seeds each were loaded into a 'Mick' applicator. Transrectal ultrasound was used for localization of the prostate and implant needles; fluoroscopy was used very little during the procedure to minimize staff exposure. As each seed was injected into the prostate, it was recorded both on paper and in computer system and final tabulation was 77 seeds were implanted. However, x-rays taken after the procedure showed only 47 seeds had been implanted, although distribution appeared satisfactory. |