ENS 43035: Difference between revisions

v t e ENS Event
08:00 Nov 29, 2006
Title	Agreement State Report - Lost Cancer Therapy Seeds
Event Description	The State provided the following information via email: Date and time of Event: 29 November 2006 (reported to DOH on 5 December 2006) Location of Event: Seattle, Washington (main campus operating room) ABSTRACT: A Central Services employee, who was to only clean bodily fluids from the exterior of a cancer therapy seed applicator post-use, apparently also opened the spring-loaded device displacing the remaining seeds. The remaining seven seeds in the applicator (one was later found in garbage, six are still missing) popped out. The six seeds were apparently flushed down the drain by mistake. Surveys cannot locate the seeds at this time. Cause, contributing factors, and corrective actions have not been determined as of this writing. At this time no consequences are expected and there has been no media attention. Isotope and Activity involved: Iodine-125, sealed brachytherapy seeds. Six seeds, total of 97.7 MegaBq (2.64 millicuries). Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): None noted or expected. Lost, Stolen or Damaged? (mfg., model, serial number): Lost, mfg/model not yet known. Disposition/recovery: To be determined. Leak test? Original, by Manufacturer, within past six months. Release of activity? The seeds were apparently released to the waste water drain. No contamination was found. Consequences: None so far, none expected. WA-06-068 * * UPDATE FROM A. SCROGGS TO W. GOTT AT 1455 ON 01/24/07 * * * The State provided the following information via email: The actual cause was determined to be inadequate training of the CS employee. The licensee has revised the procedure for handling seed implants. Now only a properly trained scrub nurse or tech will handle the applicator and accessories. At this time no consequences are expected and there has been no media attention." The six missing sources were never recovered. Notified R4DO (M. Hay) and NMSSEO (G. Morell) 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.

ENS 43035 +/-
Where
Virginia Mason Medical Center Seattle, Washington (NRC Region 4)
License number:	WN-M048-1
Organization:	Wa Division Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+176.27 h7.345 days <br />1.049 weeks <br />0.241 months <br />)
Opened:	Arden C Scroggs 16:16 Dec 6, 2006
NRC Officer:	Jason Kozal
Last Updated:	Jan 24, 2007
43035 - NRC Website
v • d • e

v t e Emergency Notification System
Virginia Mason Medical Center with Agreement State
WEEKMONTHYEAR2018-03-30T07:00:00 [Table view]
[ENS list for Virginia Mason Medical Center]

@@ Line 3: / Line 3: @@
 | facility = Virginia Mason Medical Center
 | Organization = Wa Division Of Radiation Protection
-| license number = Wn-M048-1
+| license number = WN-M048-1
 | region = 4
 | state = Washington

ENS 43035: Difference between revisions

Latest revision as of 18:33, 24 November 2018

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ENS 43035: Difference between revisions

Latest revision as of 18:33, 24 November 2018

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