ENS 43035
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
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. |
| 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 | |
Virginia Mason Medical Center with Agreement State | |
WEEKMONTHYEARENS 533442018-03-30T07:00:00030 March 2018 07:00:00
[Table view]Agreement State Misadministration of Sir-Spheres Y-90 Microspheres Resulting in an Underdose ENS 521312016-07-27T07:00:00027 July 2016 07:00:00 Agreement State Agreement State Report - Patient Received Less than the Prescribed Dose of I-131 ENS 437782007-11-09T08:00:0009 November 2007 08:00:00 Agreement State Agreement State Report - High External Radiation Levels on I-125 Medical Seed Shipment ENS 430352006-11-29T08:00:00029 November 2006 08:00:00 Agreement State Agreement State Report - Lost Cancer Therapy Seeds 2018-03-30T07:00:00 | |