ENS Event | |
|---|---|
05:00 Oct 30, 2013 | |
| Title | Agreement State Report - Radioactive Seed Incorrectly Placed On Patient |
| Event Description | The following information was received by facsimile:
Reported to NYS DOH [New York State Department of Health] on 11/12/2013. A patient received two seeds for right breast radioactive seed localization when only one was intended. The patient had two marker clips, a cylinder clip marking a benign biopsy site and a coil clip marking a papilloma. It was intended for her to only receive one seed placed at the papilloma site, but the benign site was marked with a 0.252 mCi iodine-125 seed. A second seed (0.251 mCi) was then placed to mark the correct site. The unintended dose from the 0.252 mCi seed in place for 2 days was 0.61 Gy @ 0.5 cm. Root cause analysis is ongoing. Event Report Identification Number: NY-13-06 A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. |
| Where | |
|---|---|
| Unspecified New York (NRC Region 1) | |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+676.97 h28.207 days <br />4.03 weeks <br />0.927 months <br />) | |
| Opened: | Robert Snyder 10:58 Nov 27, 2013 |
| NRC Officer: | Dong Park |
| Last Updated: | Nov 27, 2013 |
| 49587 - NRC Website | |
Unspecified with Agreement State | |
WEEKMONTHYEARENS 518322016-03-29T04:00:00029 March 2016 04:00:00
[Table view]Agreement State Agreement State Report - Medical Event ENS 495872013-10-30T05:00:00030 October 2013 05:00:00 Agreement State Agreement State Report - Radioactive Seed Incorrectly Placed on Patient ENS 489922013-04-24T04:00:00024 April 2013 04:00:00 Agreement State Agreement State Report - Prostate Seed Implant Early Termination ENS 489302013-03-25T04:00:00025 March 2013 04:00:00 Agreement State Agreement State Report - Radioactive Seed Migrated Deeper Into Tissue and Was Not Removed 2016-03-29T04:00:00 | |