ENS 54879: Difference between revisions

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{{ENS notification
{{ENS notification
| event number = 54879
| event number = 54879
| facility = Grady Memorial Hospital
| facility =  
| Organization = Georgia Radioactive Material Pgm
| Organization = Georgia Radioactive Material Pgm
| license number = GA 258-2
| license number = GA 258-2
Line 10: Line 10:
| utype =  
| utype =  
| cfr = Agreement State
| cfr = Agreement State
| emergency class = Non Emergency  
| emergency class = Non Emergency
| notification date = 09/03/2020 17:27
| notification date = 09/03/2020 17:27
| notification by = Leslines Leveque
| notification by = Leslines Leveque
Line 16: Line 16:
| event date = 08/27/2020 00:00 EDT
| event date = 08/27/2020 00:00 EDT
| last update date = 09/03/2020
| last update date = 09/03/2020
| title = Agreement State Report - Loss of Medical Seed After Removal from Patient
| title = <Td Align="Left" Scope="Row">Agreement State Report - Loss of Medical Seed After Removal from Patient
| event text = The following is a synopsis of the event received from the Georgia Radioactive Materials Program:
| event text = The following is a synopsis of the event received from the Georgia Radioactive Materials Program:
On July 31, 2020, a physician did not follow proper procedure while recording the number of seeds administered to a patient. The physician initially planned on administering one seed but decided to administer two. The physician did remove both seeds from the patient on August 3, 2020. The tracking system for the administered seeds was based on writing the number of seeds administered on a colored bracelet or arm band, which the patient wears while the seed(s) are implanted. It is removed and travels with the removed tissue through the remaining processes at the hospital. In this case, the physician did not revise the number on the bracelet, therefore during the subsequent processes, other hospital staff only looked for one seed to recover from the procedure by-products. One seed was not recovered. There was some discussion between departments prior to August 21, 2020 about the seed. Radiation Safety was not contacted.  
On July 31, 2020, a physician did not follow proper procedure while recording the number of seeds administered to a patient. The physician initially planned on administering one seed but decided to administer two. The physician did remove both seeds from the patient on August 3, 2020. The tracking system for the administered seeds was based on writing the number of seeds administered on a colored bracelet or arm band, which the patient wears while the seed(s) are implanted. It is removed and travels with the removed tissue through the remaining processes at the hospital. In this case, the physician did not revise the number on the bracelet, therefore during the subsequent processes, other hospital staff only looked for one seed to recover from the procedure by-products. One seed was not recovered. There was some discussion between departments prior to August 21, 2020 about the seed. Radiation Safety was not contacted.
On August 21, 2020, an Assistant RSO discovered the discrepancy while conducting an inventory, preparing the seeds for return to the seed vendor. Subsequent searches that included the involved staff did not recover the missing seed. After a review of the laboratory processes for analyzing the removed tissue, the hospital staff believes the missing seed was retained in the transport bin and disposed of with that bin in the bio-hazard waste stream. But, this can not be proven. It was demonstrated to not be in the frozen sample that the hospital retained. The hospital declared the seed lost on August 27, 2020.    
On August 21, 2020, an Assistant RSO discovered the discrepancy while conducting an inventory, preparing the seeds for return to the seed vendor. Subsequent searches that included the involved staff did not recover the missing seed. After a review of the laboratory processes for analyzing the removed tissue, the hospital staff believes the missing seed was retained in the transport bin and disposed of with that bin in the bio-hazard waste stream. But, this can not be proven. It was demonstrated to not be in the frozen sample that the hospital retained. The hospital declared the seed lost on August 27, 2020.
The seeds were I-125 encapsulated in titanium. Model IAI-125A.   Activity level calculated to be 145.1 microCuries at time of loss/disposal. The radioactivity is small, and the decay rate high such that this poses a low risk to the public. Based on literature, the RSO states the contact dose, assuming the seed was trapped in clothing (contact) for twelve hours to be 2.66 milliSeverts.
The seeds were I-125 encapsulated in titanium. Model IAI-125A. Activity level calculated to be 145.1 microCuries at time of loss/disposal. The radioactivity is small, and the decay rate high such that this poses a low risk to the public. Based on literature, the RSO states the contact dose, assuming the seed was trapped in clothing (contact) for twelve hours to be 2.66 milliSeverts.
The hospital has conducted a root cause analysis, and has revised its procedures and re-trained staff to prelude future loss of radioactive seeds.  
The hospital has conducted a root cause analysis, and has revised its procedures and re-trained staff to prelude future loss of radioactive seeds.
Incident #: 29
Incident #: 29
THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL
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
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
| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200914en.html#en54879
| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200914en.html#en54879
}}
}}


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Latest revision as of 12:21, 15 January 2021

ENS 54879 +/-
Where
Georgia Radioactive Material Pgm
Atlanta, Georgia (NRC Region 1)
License number: GA 258-2
Organization: Georgia Radioactive Material Pgm
Reporting
Agreement State
Time - Person (Reporting Time:+181.45 h7.56 days <br />1.08 weeks <br />0.249 months <br />)
Opened: Leslines Leveque
17:27 Sep 3, 2020
NRC Officer: Thomas Herrity
Last Updated: Sep 3, 2020
54879 - NRC Website
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