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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 54041 | 6 December 2016 05:00:00 | Agreement State | En Revision Imported Date 5/13/2019 | EN Revision Text: AGREEMENT STATE REPORT - I-125 APPLICATOR LEAK TEST FAILURE The following was received via e-mail: During a Wisconsin Department of Health Services inspection a previously unreported event was discovered. The date of the event is still being determined. While performing a manual brachytherapy procedure, the Mick applicator became jammed and the licensee switched to a different applicator to finish the procedure. Following the procedure, the (Radiation Safety Officer) RSO wiped the jammed device and found contamination so several I-125 seeds were isolated and held for decay in storage." This indicates that the device failed a leak test, which is a reportable event.
On December 6, 2016, while performing a manual brachytherapy procedure, a Mick applicator became jammed when the oncologist was attempting to insert a seed. The radiation oncologist removed the Mick applicator and switched to an extra Mick applicator with a different cartridge of seeds. A surgeon continued implanting seeds with the physicist to finish the procedure. Meanwhile, the radiation oncologist forcefully extracted the cartridge from the jammed Mick applicator. This was when the physicist/RSO believed that a seed was ruptured. Following the procedure, the RSO took the Mick applicator to the nuclear medicine hot lab and wiped the device and cartridge. The RSO found contamination on the seeds/cartridge so thirteen I-125 seeds (.333mCi each) were isolated and held for decay in storage in the hot lab. There is no indication of contamination in the operating room surveys or any expected uptake by the patient. Notified R3DO (Stoedter) and NMSS Events (via email). 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. | ||
| ENS 40687 | 13 April 2004 20:30:00 | Agreement State | Agreement State Report - Accidental Shipment of Radioactive Material | On 4/13/04, at approximately 3:30 PM CDT, the Wisconsin Radiation Protection section received a telephone call from the New York State Labor Department, Radiological Health Department. New York State Radiological Health Dept. had just been informed by one of their licensees, Mick Radio-Nuclear Instruments, Inc., that a package had been received from St. Nicholas Hospital, Sheboygan, WI. The company had found 2 radioactive brachytherapy seeds within a Mick applicator which had been returned to their company for repairs. The radioactive seeds were stuck in the Mick applicator. Mick Radio-Nuclear Instruments contacted the shipper of the device, St. Nicholas Hospital, to obtain details identifying the radionuclide. The 2 seeds have been identified as containing I-125, 0.370 milli Curies each on 3/12/04. Mick Radio-Nuclear is not licensed to receive this radioactive material which was inadvertently sent by St. Nicholas Hospital. The package was shipped on 4/8/04 and received on 4/13/04. The Wisconsin Department of Health and Family Services (DHFS) is reporting this item as a "loss of control of radioactive material to an unlicensed entity" and "potential exposure to the general public." DHFS staff are being dispatched on 4/20/04 to investigate. The radioactive material is now in the possession of the Radiological Health Department for the state of New York. St. Nicholas Hospital is working on identifying a company in New York that can take possession of the radioactive brachytherapy seeds and return them to the manufacturer. |