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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 42774 | 12 May 2003 04:00:00 | Agreement State | Agreement State Report - Medical Event | The State provided the following information regarding a previously unreported event via facsimile: The Agency (MA Radiation Control Program) received a report on 6/23/03 of a misadministration; ie., The wrong area of the scalp was treated during a treatment for a superficial scalp cancer. The wrong area of the scalp was treated because of a malfunction with the source position simulator. The misadministration was not noticed during the treatment period of May 12, 2003, thru June 5, 2003. It was discovered on June 23, 2003 while doing a similar procedure. After the source position simulator malfunction was detected, all cases that used this same device were reviewed and it was determined that only the last patient treatment was affected by this malfunction. Corrective actions were implemented to ensure this event will not happen again. Corrective action 1. Licensee reviewed all cases that involved the same device and determined that the only patient affected by this malfunction was the last one treated before discovery. 2. All HDR treatments involving variable length catheters will have the length of the catheters measured by 2 independent means. 3. The HDR manufacturer was notified of the problem encountered with the catheter measuring device. | ||
| ENS 49381 | 22 August 2013 04:00:00 | Agreement State | Agreement State Report - Missing Brachytherapy Seed | The following was received by the Commonwealth of Massachusetts via fax: On 8/22/2013, Brigham and Women's Hospital (BWH) was involved in a discrepancy in the contents of a shipment of I-125 brachytherapy seeds. The shipment was labeled to contain 71 seeds (as ordered), plus 4 seeds to be used for QC purposes. Upon opening, in preparation for administration, a count of the sources revealed only 70 of the 71 expected therapy seeds. Immediate recount and subsequent survey & investigation of the area, packaging and container showed no indication of the presence of the 71st seed. There was also no evidence of contamination detected. BWH does not believe the 71st seed was delivered. Meanwhile, the supplier, Bard Brachytherapy, Inc.'s (BBI) investigation indicates that the 71st seed was shipped to BWH. The expected 71st seed was a Bard Brachytherapy, Inc., model 125I containing 0.561 mCi (with an apparent activity of 0.330 mCi), with a reference date of 8/17/2013. 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 |