Semantic search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 50543 | 16 October 2014 13:45:00 | 10 CFR 30.50(b)(2) | Palladium-103 Brachytherapy Seed Broken | A Palladium-103 (Pd-103) brachytherapy seed (Theragenics Model 200 nominal activity 1.5 mCi) broke when the Mick shielded magazine was removed from the applicator. An activity of (approximately) 0.5 mCi for the lost portion of the seed was calculated by measuring the remaining portion of the seed. It was not recovered and presumed to have washed down a sink drain. The seed was broken and lost October 15, 2014 around 0945 (EDT). The incident was discovered around 1645. Surveys of the area for the lost portion returned no radiation above background. Contamination from the seed is remote because the Pd-103 is coated on (adhered to) a graphite pellet. No personnel radiation exposure data available. It is unlikely the person involved received measurable dose. The process for removing the cartridge at the end of a procedure will be reviewed to reduce the chance of this happening again. The licensee contacted NRC Region 3 DNMS personnel. | ||
| ENS 45237 | 30 July 2009 13:00:00 | 10 CFR 35.3045(a)(1) | Potential Medical Event Involving Novoste Beta-Cath Strontium Brachytherapy System | The licensee reported that a patient was undergoing brachytherapy treatment of the heart. During the procedure, it was determined that the source was not in the proper position. The sources were retracted and the procedure reattempted. During the reattempt, it was determined that the sources were not going into the proper position. However, the licensee was not able to retract the sources into the Novoste device. The physician removed the catheter and device as an assembly and placed in a safe box. The licensee does not know the failure mode with any degree of certainty and is sending the device to the manufacturer for evaluation. The cardiologist believes it may have been a kink in the catheter. The patient was notified of the event, and the licensee discussed the issue with NRC Region 3(G. Warren). The device is a Novoste Beta-Cath, Device number: 86865, and source number: ZB551. A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
The licensee is retracting the event because the source never entered the patient's body and the exposure to the patient was negligible. Notified the R3DO(Kunowski) and FSME (Villamar). | ||
| ENS 42600 | 22 May 2006 18:00:00 | 10 CFR 35.3047(a) | Hospital Informed of Pregnancy After Dose | On 5/3/06 Munson Medical Center administered a 150 mCi oblation dose of I-131 for thyroid cancer to a patient. Before the dose was administered the patient signed a form indicating that she was not pregnant. The dose was dispensed to the patient around 10 am. On 5/22/06 the patient called Munson Medical Center indicating that she had discovered that she was pregnant at the time of the dose. The licensee determined a calculated dose to the unborn child of 40 Rem. The patient was not yet informed of the dose to the unborn child at the time of the report. Expected medical effects of the dose are either immediate abortion or no harm since at the time of the dose organ development was not expected to have occurred. The licensee is reviewing their current policy to determine actions to prevent recurrence. |