View source for PNO-I-92-073, on 921202,discovered That 35 Mci Cs-137 Source Missing.Licensee Representative Sent to Perform Survey of Hosp Laundry Svcs Facility in Mildford,Ct.Source Recovered from Washer at Facility & Returned to Hosp

{{Adams
| number = ML20125A901
| issue date = 12/03/1992
| title = PNO-I-92-073:on 921202,discovered That 35 Mci Cs-137 Source Missing.Licensee Representative Sent to Perform Survey of Hosp Laundry Svcs Facility in Mildford,Ct.Source Recovered from Washer at Facility & Returned to Hosp
| author name = Brown K, Johansen J
| author affiliation = NRC OFFICE OF INSPECTION &amp; ENFORCEMENT (IE REGION I)
| addressee name = 
| addressee affiliation = 
| docket = 03001244
| license number = 
| contact person = 
| document report number = PNO-I-92-073, PNO-I-92-73, NUDOCS 9212090114
| document type = PRELIMINARY NOTIFICATION OF EVENT OR OCCURRENCE (PNO,, TEXT-INSPECTION &amp; AUDIT &amp; I&amp;E CIRCULARS
| page count = 2
}}
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DCS No: 03001244921202 Date: December 3,1992 MILIMINhRY_M111ELCATION OF EVENT OR UNUSUAL OCCURRENCE PN19273 This preliminary notincation constitutes EARLY notice of events of FOSSIBLE safety or public interest significance. The infonnation is as initially received without verification or evaluation, and is basically.
all that is known by the Region I staff on this date.
Facility:                                                    Licensee Emergency ClassiGcation:
         ' Yale-New Haven IIospital                                             Notification of Unusual Event                .
20 York Street                                              _         Alert New IIaven, Connecticut 06504                                        Site Area Emergency Geneul Emergency
_X        Not Applicable Docket No.: 06-00819-03 License No.. 030 01244 Event No.: NONE Event Location Code: MAT

==Subject:==
LOST-RECOVERED SOURCE /POSSIBLE TilERAPY MISADMINISTRATION Licensee's Radiation Safety Officer (RSO) infonned the NRC Emeryc=y Operations Center at 6:10 p.m., on December 2,1992, that earlier that aftemoon it was discovered that a 35 millicurie cesium-137 source was missing. The source, one of four inserted in a Fletcher apparatus used in the treatment of cancer of the cervix, was implanted in a female patient on November 30,1992. The sources and apparatus were removed at 4:00 p.m. on December 1,1992, and returned to the licensee's biachytherapy storage area. While the patient and the patient's room were surveyed at the time of source removal and found irce of radioactivity, the sources were not counted until the afternoon of December 2,1992. A technician cleaning the sources on December 2, i992, could not account for all four sources n: moved and reponed the loss of the source to the RSO. Licensee did a thorough survey of the hospital and did not find the source. A licensee representative was sent to perform a survey at the hospital's laundry services facility in Milford, CT. The source was recovered frum a washer at the laundry services facility and retumed to the hospital. Water samples from the laundry and a leak test of the sealed source found the source to be intact. The licensee believes that the source may have been lost on November 30, when tne sources were placed in the patient, and that the source did not leave the hospital until the laundry was picked up on December 2,1992. The Jicensee stated the radiation dose rate from the cesium-137 source is 11.5 millirern/ hour at a distance of 1 meter. 'Ite licensee is conducting an investigation into the circumstances of this event. Region 1 is dispatching inspectors to review the licensee's actions in this matter. The State of Connecticut has been notified of this event.
l Region I is prepared to respond to media inquiries.
This information is current as of 10:00 a.m., December 3,1992.
l
!-        CONTACT:            Keith Brown              Jenny Johansen Q15) 337-5048           (215) 337-5304 L
070110 I                        9212090114 921203                                                                               g PDR     18cE PNO-I-92-073          PDR                                                                      q-d        h

_ _ . ~ -. . _                . _    _ _ _ _ .        .
DCS No: 03001244921202                                                . 2--                                               1 Date: DEember 3,1992 PRIILIMINAih' NOTIEICATION OF EVENT OR UNUSUAL OCCURRENCE PN19273 DISTRIBUTION:
QEEN                               h1NHH                     L-St.          NL               Mail:        ADM:DMB Chainnan Selin                     AEOD *
* PDR            RES                           DOT:Trans only"  )
Comm. Rogers                       IRM Comm. Curtiss                      OIG"                                                      NRC Ops Ctr"            _
Comm. Remick                                                                                             j Comm. de Planque                                                                             INPO** M dO['"
OCAA                                                                                         NS AC* *       ' %f'' w OIP Ehi!Uns OCA               EDO              ACRS" OGC               NMSS OPA               NRR** (Phone Verif: A. Byrdsong 964-1168 or 964-1166)
OE OSP               Regional Offices                        RI Resident Office __.
Iiww OlG                                     Licensee:
(Reactor Licensees)
  ** Gener kst fu sendmg I'Ns t'y FAX Region i Form 83 (Rev. November 1992)
I p,nq r}}

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