PNO-I-96-056, on 960806,licensee Called NRC Operations Ctr to Rept Loss of Seeds.Licensee Continuing Search & Investigation of Cause of Incident,Including Adequacy of Procedures for Retrieval,Accounting & Inventory: Difference between revisions

From kanterella
Jump to navigation Jump to search
VisualWikitext
StriderTol Bot insert
 
StriderTol Bot change
 
Line 15: Line 15:
| page count = 3
| page count = 3
}}
}}
{{#Wiki_filter:DCS No.: 03001244960806   I Date: August 7, 1996       i PRELIMINARY NOTIFICATION OF EVENT OR UNVSUAL OCCURRENCE PN1-56                                 )
{{#Wiki_filter:DCS No.:
This preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public interest significance.       The information is as initially received without             l verification or evaluation, and is basically all that is known by the Region I staff on this date.
03001244960806 Date: August 7, 1996 i
PRELIMINARY NOTIFICATION OF EVENT OR UNVSUAL OCCURRENCE PN1-56
)
This preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public interest significance.
The information is as initially received without verification or evaluation, and is basically all that is known by the Region I staff on this date.
Facility:
Facility:
Yale-New Haven Hospital 20 York Street New Haven, CT 06504                                 Licensee Emergency Classification:         l Notification of Unusual Event Alert Site Area Emergency General Emergency Docket No.:       030-01244                                                                     l License No.: 06-00819-03                                                                       !
Yale-New Haven Hospital 20 York Street New Haven, CT 06504 Licensee Emergency Classification:
ve     o tion Code:     H                                                           g
Notification of Unusual Event Alert Site Area Emergency General Emergency Docket No.:
030-01244 License No.: 06-00819-03 g
ve o tion Code:
H


==SUBJECT:==
==SUBJECT:==
LOSS OF 10 DINE-125 SEEDS                                             -
LOSS OF 10 DINE-125 SEEDS At approximately 3:20 pm on August 6,1996, the licensee called the NRC Operations Center to report the loss of 5 iodine-125 sources (seeds), with activity of 0.5 l
At approximately 3:20 pm on August 6,1996, the licensee called the NRC Operations Center to report the loss of 5 iodine-125 sources (seeds), with activity of 0.5                 l nillicuries each. On February 26, 1996 the licensee received 50 iodine-125 seeds, with activity of 3 millicuries each. Of the 50 seeds the licensee used 49 seeds in an eye           ,
nillicuries each. On February 26, 1996 the licensee received 50 iodine-125 seeds, with activity of 3 millicuries each. Of the 50 seeds the licensee used 49 seeds in an eye plaque to treat a patient. On March 6, 1996, the seeds were returned to a vial after i
plaque to treat a patient. On March 6, 1996, the seeds were returned to a vial after           i the seeds were retrieved from the eye plaque. The licensee reported that on March 6, 1996, the seeds were counted and verified to be 50 seeds. On July 26, 1996 the vial             ,
the seeds were retrieved from the eye plaque. The licensee reported that on March 6, 1996, the seeds were counted and verified to be 50 seeds.
reportedly containing 50 seeds was taken to the operating room to implant the seeds in           I a patient. The seeds were placed in a glass dish, the dish covered with a piece of gauze and placed in a stainless steel container, and autoclaved prior to implanting in the patient. The licensee stated that, after the physician implanted 36 seeds in the patient only 9 seeds were left in the vial, versus the expected 14 seeds. The licensee surveyed the operating room, but failed to locate the 5 missing seeds. On a resurvey             l of the operating room, 3 seeds were found in a blood suction bottle. The licensee               l believes that these 3 seeds were dislodged from the 36 seeds that were just implanted           I into the patient and, therefore, do not account for the 5 missing seeds.                       j Seed accountability in the patient could not be verified through X-rays because the patient had an earlier implant of 80 seeds in the same area (oral cavity) and fillings in the teeth obscured some of the seeds in the X-rays.
On July 26, 1996 the vial reportedly containing 50 seeds was taken to the operating room to implant the seeds in a patient.
The licensee believes that either the sources were lost in March 1996, with a total activity at that time of about 15 millicuries, or the sources were lost on July 26, 1996, with a total activity at that time of about 2.5 millicuries. The licensee is continuing its search and investigation of the cause of this incident, including the adequacy of procedures for retrieval, accounting, inventory, and control of radioactive seeds.
The seeds were placed in a glass dish, the dish covered with a piece of gauze and placed in a stainless steel container, and autoclaved prior to implanting in the patient. The licensee stated that, after the physician implanted 36 seeds in the patient only 9 seeds were left in the vial, versus the expected 14 seeds. The licensee surveyed the operating room, but failed to locate the 5 missing seeds. On a resurvey of the operating room, 3 seeds were found in a blood suction bottle.
The licensee believes that these 3 seeds were dislodged from the 36 seeds that were just implanted into the patient and, therefore, do not account for the 5 missing seeds.
j Seed accountability in the patient could not be verified through X-rays because the patient had an earlier implant of 80 seeds in the same area (oral cavity) and fillings in the teeth obscured some of the seeds in the X-rays.
The licensee believes that either the sources were lost in March 1996, with a total activity at that time of about 15 millicuries, or the sources were lost on July 26, 1996, with a total activity at that time of about 2.5 millicuries.
The licensee is continuing its search and investigation of the cause of this incident, including the adequacy of procedures for retrieval, accounting, inventory, and control of radioactive seeds.
Region I will continue its review of the licensee's performance in this area.
Region I will continue its review of the licensee's performance in this area.
The State of Connecticut has been notified.       Region I is prepared to respond to media inquiries.
The State of Connecticut has been notified.
Region I is prepared to respond to media inquiries.
Igl


==Contact:==
==Contact:==
Neelam Bhnla (610)337-6188 Mohamed Shanbaky (610)337-5209 Igl 0 (96OSo?O30il)Xer N
Neelam Bhnla Mohamed Shanbaky 0
(610)337-6188 (610)337-5209 (96OSo?O30il)Xer N


HMSS LICENSEE EVENT REPORT License No. o6 - o e,sn 9 - t 1 Docket No.     O 3 c3 - o i     7_ y y MLER-RI               7 5 - fbt' LICENSEE     Y' A - rd m M au                       C3,1 a
HMSS LICENSEE EVENT REPORT License No.
m;qvc                 .
o6 - o e,sn 9 - t 1 Docket No.
EVENT DESCRIPTION       LM     R_ m     ( f r -f 2 r s u b         o5-4           M )+'YO 2' " " ' '/2m n s   wu EVENT DATE     9/a ( / 9 C r  3/6/9L           REPORT DATE         9/ 6/ 96
O 3 c3 - o i 7_ y y MLER-RI 7 5 - fbt' LICENSEE Y' A - rd m M au C3,1 a
: 1. REPORTING REQUIREMENT
m;qvc EVENT DESCRIPTION LM R_ m
(       0 CFR 20.2201 Theft or loss           ()   10 CFR 35.33 Hisadministration
( f r -f 2 r s u b o5-4 M )+'YO 2' " " ' '/2m n s wu EVENT DATE 9/a ( / 9 C 3/6/9L REPORT DATE 9/ 6/ 96 r
()     10 CFR 20.2203 30 Day Report           () License Condition
1.
()     10 CFR 30.50 Report
REPORTING REQUIREMENT
() Other
(
: 2. REGION I RESPONSE
0 CFR 20.2201 Theft or loss
()     Immediate Site Inspection             Inspector /Date
()
() Special Inspection                         Inspector /Date
10 CFR 35.33 Hisadministration
() Telephone Inquiry                         Inspector /Date v , Preliminary Notification               () Daily Report ya.,
()
(g)/
10 CFR 20.2203 30 Day Report
(      Information Entered on the Region I Log
() License Condition
()
10 CFR 30.50 Report
() Other 2.
REGION I RESPONSE
()
Immediate Site Inspection Inspector /Date
() Special Inspection Inspector /Date
() Telephone Inquiry Inspector /Date (g)/
v, Preliminary Notification
() Daily Report
(
Information Entered on the Region I Log ya.,
() Review at Next Routine Inspection
() Review at Next Routine Inspection
() Report Referred to
() Report Referred to 3.
: 3. REPORT EVALUATION
REPORT EVALUATION
([AescriptionofEvent                         (       rrective Actions (v( , Levels of RAM Involved                 () Calculation Adequate
([AescriptionofEvent
( ( Cause of Event                           () Letter to Licensee Requesting Additional Information
(
: 4. SPECIAL INSTRUCTIONS OR COMMENTS 5 0003 Completed by _. 1           hki             w               Date     / / > i / 5 -)
rrective Actions (v(, Levels of RAM Involved
Reviewedby(                                                   Date     /       /fL7
() Calculation Adequate
                              /
( ( Cause of Event
                                                                                  'f - (
() Letter to Licensee Requesting Additional Information 4.
g:\las\mlerform (Revised 1/6/95) O f
SPECIAL INSTRUCTIONS OR COMMENTS 5 0003 Completed by _. 1 hki w
                                                                                        -p so P}}
Date
/ / > i / 5 -)
Reviewedby(
Date
/
/fL7
'f - (
/
g:\\las\\mlerform (Revised 1/6/95) O f
so P
-p}}


{{PNO-Nav|region=I}}
{{PNO-Nav|region=I}}

Latest revision as of 05:46, 12 December 2024

PNO-I-96-056:on 960806,licensee Called NRC Operations Ctr to Rept Loss of Seeds.Licensee Continuing Search & Investigation of Cause of Incident,Including Adequacy of Procedures for Retrieval,Accounting & Inventory
ML20134B830
Person / Time
Site: 03001244
Issue date: 08/07/1996
From: Bhalla N, Shanbaky M
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20134B832 List:
References
PNO-I-96-056, NUDOCS 9608070308
Download: ML20134B830 (3)
v • d • e


DCS No.:

03001244960806 Date: August 7, 1996 i

PRELIMINARY NOTIFICATION OF EVENT OR UNVSUAL OCCURRENCE PN1-56

)

This preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public interest significance.

The information is as initially received without verification or evaluation, and is basically all that is known by the Region I staff on this date.

Facility:

Yale-New Haven Hospital 20 York Street New Haven, CT 06504 Licensee Emergency Classification:

Notification of Unusual Event Alert Site Area Emergency General Emergency Docket No.:

030-01244 License No.: 06-00819-03 g

ve o tion Code:

H

SUBJECT:

LOSS OF 10 DINE-125 SEEDS At approximately 3:20 pm on August 6,1996, the licensee called the NRC Operations Center to report the loss of 5 iodine-125 sources (seeds), with activity of 0.5 l

nillicuries each. On February 26, 1996 the licensee received 50 iodine-125 seeds, with activity of 3 millicuries each. Of the 50 seeds the licensee used 49 seeds in an eye plaque to treat a patient. On March 6, 1996, the seeds were returned to a vial after i

the seeds were retrieved from the eye plaque. The licensee reported that on March 6, 1996, the seeds were counted and verified to be 50 seeds.

On July 26, 1996 the vial reportedly containing 50 seeds was taken to the operating room to implant the seeds in a patient.

The seeds were placed in a glass dish, the dish covered with a piece of gauze and placed in a stainless steel container, and autoclaved prior to implanting in the patient. The licensee stated that, after the physician implanted 36 seeds in the patient only 9 seeds were left in the vial, versus the expected 14 seeds. The licensee surveyed the operating room, but failed to locate the 5 missing seeds. On a resurvey of the operating room, 3 seeds were found in a blood suction bottle.

The licensee believes that these 3 seeds were dislodged from the 36 seeds that were just implanted into the patient and, therefore, do not account for the 5 missing seeds.

j Seed accountability in the patient could not be verified through X-rays because the patient had an earlier implant of 80 seeds in the same area (oral cavity) and fillings in the teeth obscured some of the seeds in the X-rays.

The licensee believes that either the sources were lost in March 1996, with a total activity at that time of about 15 millicuries, or the sources were lost on July 26, 1996, with a total activity at that time of about 2.5 millicuries.

The licensee is continuing its search and investigation of the cause of this incident, including the adequacy of procedures for retrieval, accounting, inventory, and control of radioactive seeds.

Region I will continue its review of the licensee's performance in this area.

The State of Connecticut has been notified.

Region I is prepared to respond to media inquiries.

Igl

Contact:

Neelam Bhnla Mohamed Shanbaky 0

(610)337-6188 (610)337-5209 (96OSo?O30il)Xer N

HMSS LICENSEE EVENT REPORT License No.

o6 - o e,sn 9 - t 1 Docket No.

O 3 c3 - o i 7_ y y MLER-RI 7 5 - fbt' LICENSEE Y' A - rd m M au C3,1 a

m;qvc EVENT DESCRIPTION LM R_ m

( f r -f 2 r s u b o5-4 M )+'YO 2' " " ' '/2m n s wu EVENT DATE 9/a ( / 9 C 3/6/9L REPORT DATE 9/ 6/ 96 r

1.

REPORTING REQUIREMENT

(

0 CFR 20.2201 Theft or loss

()

10 CFR 35.33 Hisadministration

()

10 CFR 20.2203 30 Day Report

() License Condition

()

10 CFR 30.50 Report

() Other 2.

REGION I RESPONSE

()

Immediate Site Inspection Inspector /Date

() Special Inspection Inspector /Date

() Telephone Inquiry Inspector /Date (g)/

v, Preliminary Notification

() Daily Report

(

Information Entered on the Region I Log ya.,

() Review at Next Routine Inspection

() Report Referred to 3.

REPORT EVALUATION

([AescriptionofEvent

(

rrective Actions (v(, Levels of RAM Involved

() Calculation Adequate

( ( Cause of Event

() Letter to Licensee Requesting Additional Information 4.

SPECIAL INSTRUCTIONS OR COMMENTS 5 0003 Completed by _. 1 hki w

Date

/ / > i / 5 -)

Reviewedby(

Date

/

/fL7

'f - (

/

g:\\las\\mlerform (Revised 1/6/95) O f

so P

-p

Retrieved from "https://kanterella.com/w/index.php?title=PNO-I-96-056,_on_960806,licensee_Called_NRC_Operations_Ctr_to_Rept_Loss_of_Seeds.Licensee_Continuing_Search_%26_Investigation_of_Cause_of_Incident,Including_Adequacy_of_Procedures_for_Retrieval,Accounting_%26_Inventory&oldid=4233793"