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At 0634 hrs on June 20, 2006, (the Directo … At 0634 hrs on June 20, 2006, (the Director of the Texas Department of Health) received a call on the way to the office from the Director of Radiology for Ben Taub General Hospital in Houston, TX. He relayed brief details of a recovered source that was either taken out of a patient or never placed in an after loading appliance utilized for the treatment of a cervical cancer patient. In the words of the Radiation Safety Officer with proper names redacted:</br>On Sunday, June 18, 2006 at 4:40 am a Cesium-137 source, 3M model 6501(6D6C-CA), serial # 06965, with an activity of approximately 17 mCi (milliCuries) was noted to be missing from a patient who was undergoing a tandem and ovoid implant for cervical cancer. The patient had applicator placement (uterine tandem and two Fletcher ovoids) at Ben Taub General Hospital (BTGH), on Friday 6/16/2006. The Cesium sources (4 in all; 2 in the tandem and 1 each in the ovoid) had been placed in the patient by the Radiation Oncologist at 3:40 pm for a 37 hour implant. When the right ovoid source was noted to be missing at the time of unloading; the patient, room, Nursing Unit 6B of the hospital, and the route of transport of the sources from the BTGH Radiotherapy Department to the patient's room were surveyed using both a sodium iodide detector and a conventional air-ionization type survey meter by both the Radiation Oncologist and Medical Physicist. The BTGH Radiation Safety Officer was notified at 8:20 am Sunday morning of the apparent missing source. Upon further investigation, it was learned that the bed sheets of the patient had been changed at 3 pm on Saturday, 6/17/2006, and this dirty linen was placed in the linen cart on 6B. It was subsequently taken to a truck at the BTGH loading dock and transported to the Texas Medical Center Laundry facility. On Monday morning, 6/19/06, the director of this facility was contacted and subsequently the facility was surveyed. The Cs-137 source was recovered at 10:30 a.m., from the third floor and transported back to the BTGH Radiotherapy Department using an appropriately shielded container.</br> </br>The names of all the persons who potentially may have come into contact with the Cesium source were obtained and notified. This list included thirty-five (35) individuals of both hospital and laundry services personnel.</br>Upon further review by staff in assembling the documents for the incident file, the attachments to the June 26, 2006 e-mail was examined at 1400hrs on July 7, 2006. At that time DSHS staff realized that this was a lost/found source with quantities >1,000 X Appendix C value requiring immediate reporting to NMED. However, staff reviewed the operational setting and in the absence of the licensee's report demonstrating an exposure exceeding of 100mrem to a member of the public, the incident may not be reportable. Further investigation is on-going.</br>Texas Incident: I-8350stigation is on-going.
Texas Incident: I-8350
09:40:00, 18 June 2006 +
15:43:00, 7 July 2006 +
09:40:00, 18 June 2006 +
At 0634 hrs on June 20, 2006, (the Directo … At 0634 hrs on June 20, 2006, (the Director of the Texas Department of Health) received a call on the way to the office from the Director of Radiology for Ben Taub General Hospital in Houston, TX. He relayed brief details of a recovered source that was either taken out of a patient or never placed in an after loading appliance utilized for the treatment of a cervical cancer patient. In the words of the Radiation Safety Officer with proper names redacted:</br>On Sunday, June 18, 2006 at 4:40 am a Cesium-137 source, 3M model 6501(6D6C-CA), serial # 06965, with an activity of approximately 17 mCi (milliCuries) was noted to be missing from a patient who was undergoing a tandem and ovoid implant for cervical cancer. The patient had applicator placement (uterine tandem and two Fletcher ovoids) at Ben Taub General Hospital (BTGH), on Friday 6/16/2006. The Cesium sources (4 in all; 2 in the tandem and 1 each in the ovoid) had been placed in the patient by the Radiation Oncologist at 3:40 pm for a 37 hour implant. When the right ovoid source was noted to be missing at the time of unloading; the patient, room, Nursing Unit 6B of the hospital, and the route of transport of the sources from the BTGH Radiotherapy Department to the patient's room were surveyed using both a sodium iodide detector and a conventional air-ionization type survey meter by both the Radiation Oncologist and Medical Physicist. The BTGH Radiation Safety Officer was notified at 8:20 am Sunday morning of the apparent missing source. Upon further investigation, it was learned that the bed sheets of the patient had been changed at 3 pm on Saturday, 6/17/2006, and this dirty linen was placed in the linen cart on 6B. It was subsequently taken to a truck at the BTGH loading dock and transported to the Texas Medical Center Laundry facility. On Monday morning, 6/19/06, the director of this facility was contacted and subsequently the facility was surveyed. The Cs-137 source was recovered at 10:30 a.m., from the third floor and transported back to the BTGH Radiotherapy Department using an appropriately shielded container.</br> </br>The names of all the persons who potentially may have come into contact with the Cesium source were obtained and notified. This list included thirty-five (35) individuals of both hospital and laundry services personnel.</br>Upon further review by staff in assembling the documents for the incident file, the attachments to the June 26, 2006 e-mail was examined at 1400hrs on July 7, 2006. At that time DSHS staff realized that this was a lost/found source with quantities >1,000 X Appendix C value requiring immediate reporting to NMED. However, staff reviewed the operational setting and in the absence of the licensee's report demonstrating an exposure exceeding of 100mrem to a member of the public, the incident may not be reportable. Further investigation is on-going.</br>Texas Incident: I-8350stigation is on-going.
Texas Incident: I-8350
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00:00:00, 7 July 2006 +
01303 +
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22:38:27, 24 September 2017 +
15:43:00, 7 July 2006 +
19.252 d (462.05 hours, 2.75 weeks, 0.633 months) +
09:40:00, 18 June 2006 +
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