Semantic search
Jump to navigation
Jump to search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 56770 | 28 September 2023 04:00:00 | Agreement State | Agreement State - I-125 Seed Inadvertently Transected | The following information was provided by the Pennsylvania Bureau of Radiation Protection via email: On September 28, 2023, staff from Magee Pathology department called the (University of Pittsburgh) radiation safety office to report that they had accidentally transected an I-125 seed used for radioactive seed localization (RSL) in breast tissue during the pathology processing in the laboratory. The seed was a Best Medical International Model 2301 containing 169 microcuries of I-125. Two staff members were involved, and they were told to sequester in the room until personnel from radiation safety could respond. Shortly after, radiation safety personnel performed surveys to determine the extent of the contamination. No personnel contamination was observed. All contamination was discovered in waste material and on the tissue samples. The transected seed was contained. The radiation safety office took possession of the damaged seed and all radioactive waste. At the time of reporting, it is estimated that approximately 50 percent of the activity was lost to open contamination, which is greater than 1 annual limit on intake (ALI) of I-125, and therefore reached the criteria for (10 CFR) 22.2202 reportability. Workers had bioassays performed for thyroid exposure and all returned negative. PA event report ID: PA230028 | ||
| ENS 55139 | 12 March 2021 05:00:00 | Agreement State | Dose Received Was Less than Prescribed Dose | The following was received via an email from the state of Pennsylvania: The Department (PA Bureau of Radiation Protection) received notification from a licensee on March 12, 2021 of medical event involving yttrium-90 TheraSphere (TM). The licensee believes a patient received only 2 milliCurie of the 63.7 milliCurie prescribed dose. The connection piece between the Therasphere (TM) apparatus and the patient catheter failed when the injection started. All contamination was contained with absorbent pads that were located below the connection. The room, staff and patient were extensively surveyed and not found to be contaminated. The patient and the prescribing physician have been informed. No adverse effects to the patient are anticipated. The Department is currently in contact with the licensee and will update this event as soon as more information is provided. Pennsylvania Event Report ID No: PA210002 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 51567 | 20 November 2015 05:00:00 | Agreement State | Agreement State Report - Lost Radioactive Seed | The following was received from the Commonwealth of Pennsylvania via email: The licensee discovered the event on November 23, 2015 and notified the Department (Commonwealth of Pennsylvania) on November 25, 2015. It is reportable as per 10 CFR 20.2201(a)(1)(ii). An iodine-125 (I-125) seed was used for radioactive seed localization of a breast lesion. After surgical excision of the breast tissue at an outpatient surgical center, the specimen was placed in a plastic bag and imaged radiographically to confirm the presence of the seed. The seed was noted to be at the edge of the specimen. The specimen was then transferred to a plastic container for transport to the main hospital pathology department. When the specimen was received at pathology, a survey indicated that there was no seed present. Radionuclide: I-125 Seed Manufacturer: Best Medical Model No.: 2301 Activity: 113 microCi The licensee assumes the seed became separated from the specimen and remained in the plastic bag which was disposed as biohazardous waste. A survey of the surgical center was performed, but the seed was not able to be located. A reactive inspection is planned by the Department. More information will be provided upon receipt. Event Report ID No: PA150030 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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 48286 | 6 September 2012 04:00:00 | Agreement State | Agreement State Report - Yttrium-90 Microspheres Administered to the Wrong Treatment Site | On September 6, 2012, the (Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (PADEPBRP)) Central Office received notification via a phone call about this medical event. The patient received an administration of approximately 1.4 millicuries (mCi) of Y-90 microspheres to the wrong treatment site. The intended treatment was to administer approximately 24 mCi to the left lobe of the liver through three different arteries. During the administration of one of the split doses, the Interventional Radiologist (IR) incorrectly positioned the catheter in the right hepatic artery. A portion of the one split dose was administered to the right lobe of the liver before the IR realized that the catheter was not in the correct artery. Cause of the event: Human Error. Actions: Both the referring physician and the patient have been notified of the medical event. The (PADEPBRP) plans to do a reactive inspection. 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. |