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| Entered date | Event description | |
|---|---|---|
| ENS 43827 | 7 December 2007 15:32:00 | A leaking sealed source discovered on Monday, December 3rd 2007, at the Scottsdale Radiation Oncology Center in our hot lab. This seed is listed as a sealed source containing Cs-131, from the company IsoRay Medical, Inc. The activity contained inside this seed was 3.12 mCi (milli-Curies) of Cs-131. The incident occurred following a patient prostate implant. This seed had become jammed in a Mick Applicator cartridge. After the patient procedure in the hospital had finished, surveys of linen, OR (Operating Room), patient bed, and trash showed readings of background with the GM (Geiger-Mueller) survey meter. The seed, still in the cartridge, was packaged inside the container it had originally arrived in and shipped to the (Scottsdale Radiation Oncology Center). Upon its arrival in Scottsdale, the package was surveyed externally with a wipe test which showed no contamination on the external package. It was at (Scottsdale Radiation Oncology Center) that we ascertained that the seed had leaked into its internal container and contaminated the Mick cartridge it resided in. Our personnel that regularly loads seeds was removing it with bare hands since the outside container had been surveyed and showed no contamination. The seed was dislodged into a lead container behind a leaded shield, and the cartridge was surveyed by a GM tube. Since the GM tube responded, our personnel then placed the cartridge into a lead container and then surveyed her fingers. Upon realizing she was contaminated she informed the ARSO (Assistant Radiation Safety Officer). She was directed to wash with soap and water. After about 15 minutes her hands showed no residual contamination with a GM and pancake probe with open face. The seeds were then placed into a capped glass container and into a marked leaded container. The original shipping box was surveyed, and the decision was to bag the entire box, and store in locked cabinet for 70 days (10 half lives). A survey will be performed to prove that the container is background before it is put back into service. All areas and personnel were surveyed with the GM and pancake probe open faced, to confirm no residual contamination. The area and personnel were clean and further wipe tests showed only background. The physician was informed of incident as well as ARRA (Arizona Radiation Regulatory Agency), and IsoRay's health physicist. A calculation showed that the 15 minutes of exposure to the personnel extremities did not exceed the regulation AAC R12-1-445 of 50 rads that is reportable. As a corrective action, personnel will now wear rubber gloves until all cartridges are examined following the return of any seeds. |