Semantic search
Jump to navigation
Jump to search
| Entered date | Event description | |
|---|---|---|
| ENS 45233 | 28 July 2009 19:00:00 | The following information was received from the State of California Radiologic Health Branch via email: Pomona Valley Hospital Medical Center discovered an Iodine-125 seed shortage of 10 seeds (.449 mCi/seed) all in one cartridge on Monday July 27, 2009 at approximately 1800 hours during a permanent prostate seed implant. The physician performing the implant discovered the cartridge missing when he opened the sterilized package. These I-125 sources are used for permanent implant into the prostate for therapy. The physicist last saw the 7 cartridges and 100 seeds in the Hot Lab, located in the basement of the hospital on Friday July 24, 2009 at approximately 1050. Of the 100 seeds in the order, he assayed the cartridge with 9 seeds plus 1 for a total of 10 seeds. Once he completed the assay he re-loaded the cartridge with all 10 seeds, and placed the cartridge back in the storage block with the other 6 cartridges (containing 15 seeds each), and returned the storage block to the lunch box (used for carrying the cartridges to surgery). He placed the lunch box behind the loading shield and secured the Hot Lab, anti-room and exterior door before leaving the area. On Monday at approximately 1510 the lunch box was retrieved form the locked Hot Lab and taken, with the seeds inside, to the Operating Room (OR). Possession of the lunch box was transferred to an RN, who called Sterile Processing to retrieve the seeds from her desk for sterilization. A staff member from Sterile Processing retrieved the lunch box from RN's desk (located in the surgery suite area) to prepare for sterilization. The Sterile Processing staff member had to be directed on how to wrap the seeds as he had never prepared the seeds for sterilization before. The wrapped seeds were taken back up to Surgery and placed in Sterilizer #34. Once the sterilization process was complete, the seed package was delivered to OR #2 where the implant procedure was being performed. Once the physician discovered the missing cartridge during the procedure, the Medical Physicist and RSO, was notified and immediately went to the Hot Lab in attempt to locate the missing cartridge. The RSO contacted the physicist by phone who confirmed all 100 seeds in 7 cartridges were accounted for on Friday morning when he assayed them. The RSO also interviewed the staff member who prepared the seeds for Sterile processing to ask him if he dropped the lunch box and perhaps lost a cartridge, which the staff member denied. The RSO then took the spill meter (TBM survey meter) and surveyed Sterile Processing and both elevators. The Hot Lab was taken apart and thoroughly surveyed, as well as the anti-room and packaging materials. No evidence of radioactive materials was found. The implant procedure concluded without incident. The dosimetry plan for the patient called for 90 seeds which they had available. At the completion of the implant we had no seeds left over. All 90 seeds were implanted into the patient and the patient is doing well. In no way was the patient's care compromised by this set of missing I-125 seeds. Bard (Brachytherapy, Inc), the manufacturer of the sources was called to verify the shipment was in fact complete, but at 2100 hours their time July 27, 2009, no one was available. The hospital was able to contact Bard, located in Carol Stream, Illinois the following day concerning a preliminary investigation of the order. According to Bard's records the assembler of the order pulled 100 seeds off the line and 7 cartridges from inventory. None of their other customers reported receiving 10 seeds not ordered. Bard will not provide a formal report of our order until it has passed their legal department. Last night (July 27, 2009) Security was notified and started a formal investigation of the incident. The Hospital Administration, the Chief of Security, and the Manager of Sterile Processing were notified and explained the seriousness of the situation. Today (July 28, 2009) Pomona Valley Hospital Medical Center is continuing to search for the seeds and taking statements from all the involved associates. The Lot Number for the sources is: BBTG0030. Note that this report was edited to remove reference to the names of the employees involved. California Report number 072809. 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. |