ENS 42354
ENS Event | |
|---|---|
06:00 Feb 21, 2006 | |
| Title | Agreement State - Loss of Iridium Seed Strand Following Medical Treatment |
| Event Description | The following is a summary of information provided by the State via email:
The licensee's Radiation Safety Officer indicated that a gynecological implant of seeds contained in a nylon ribbon were missing at the completion of a patient treatment. The "strand" contained 10 seeds of 0.675 milliCi, each, which was part of a treatment that included 9 total strands of both Cs-137 and Ir-192 sources. The lost strand contained 10 Ir-192 seeds. A resident physician removed the strands at the end of the treatment on the evening of 2/18/06. The treatment had begun on 2/15/06. After returning the strands to the radiation oncology lab it was noted that only 8 strands were present, rather than the 9 which were initially implanted. The patient was thoroughly surveyed and eventually x-ray'd to confirm the missing strand did not remain in the patient. The operating room, the patient's room, the remaining linen and trash from the patient's room, the hallway between the patient's room and the radiation oncology source storage location, the entire nursing floor, the radiation oncology department, the hospital's linen holding facility, the biohazardous waste holding facility and loading docks were all monitored without any success of locating the strand. The patient had been essentially immobilized for the treatment and had received a Foley catheter for relieving her bladder. As such, use of the toilet facilities were not likely (although they too were monitored). Surveys were conducted with instruments that were likely to detect the radiation field associated with almost 7 mCi of Ir-192 (i.e., 4 to 5 milliRem/hr at 1 meter) by the staff. Interviews were conducted with the nursing staff to determine additional details regarding handling of trash and linen from the patient's room. Although the licensee's surveys showed no elevated levels present at the time, the licensee indicated that waste and linen from the room would be held pending potential surveys by the Division. The licensee has also monitored their contracted biohazardous waste treatment facility in Cicero, IL on 2/20/06 with negative results. They also planned to visit the linen laundering facility in Palwaukee, IL on the slim chance that the strand was carried off in soiled linens that might have been changed during the patient's stay. The resident involved, the residency staff and the residency director received additional instruction regarding established procedures, in conjunction with this event, with regards to explanation of sources and accounting procedures. Similarly, the nursing staff was interviewed and refreshed on established procedures with regards to linen and waste processing from patients' rooms. The patient was scheduled to return for a follow up visit on 2/22/06 at which time she was going to be interviewed again to determine if there was any additional information she could provide to help locate the missing strand. Illinois Report #IL060013
The missing radioactive sources reported by the Illinois Emergency Management Agency (IEMA) on February 21, 2006 at 17:21 from Northwestern Memorial Hospital have been recovered by the facility's radiation safety officer. A radiation monitor alarm was reported to IEMA by the Prairie Hills Landfill staff in Morrison, IL on 2/21/2006. IEMA personnel investigated that alarm yesterday [02/22/06] and confirmed the presence of Ir-192 by gamma spectroscopy as part of a load of trash that was traced back to the hospital's laundry service provider. Arrangements were made to have the ribbon of 10 sources picked up by hospital staff this morning and returned to the hospital for proper disposal. Notified R3DO (Hills) and NMSS EO (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. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source |
| Where | |
|---|---|
| Northwestern Memorial Hospital Chicago, Illinois (NRC Region 3) | |
| License number: | Il-01037-02 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+11.35 h0.473 days <br />0.0676 weeks <br />0.0155 months <br />) | |
| Opened: | Daren Perrero 17:21 Feb 21, 2006 |
| NRC Officer: | Bill Huffman |
| Last Updated: | Feb 23, 2006 |
| 42354 - NRC Website
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Northwestern Memorial Hospital with Agreement State | |
WEEKMONTHYEARENS 570972024-04-30T05:00:00030 April 2024 05:00:00
[Table view]Agreement State Medical Event ENS 558422022-04-11T05:00:00011 April 2022 05:00:00 Agreement State Patient Received Dose Less than Prescribed ENS 557162022-01-27T06:00:00027 January 2022 06:00:00 Agreement State Patient Underdose ENS 557042021-02-15T06:00:00015 February 2021 06:00:00 Agreement State Patient Underdose ENS 467922011-04-27T05:00:00027 April 2011 05:00:00 Agreement State Agreement State Report - Underdose Due to Clumping in the Delivery Device ENS 448162009-01-29T06:00:00029 January 2009 06:00:00 Agreement State Agreement State Report - Personnel Contamination from I-131 Spill in Hot Lab ENS 423542006-02-21T06:00:00021 February 2006 06:00:00 Agreement State Agreement State - Loss of Iridium Seed Strand Following Medical Treatment 2024-04-30T05:00:00 | |