ENS 42627
ENS Event | |
|---|---|
07:00 May 30, 2006 | |
| Title | Agreement State Report - Damaged Sources |
| Event Description | The State provided the information via e-mail:
This is notification of an event in Washington State as reported to or investigated by the WA Department of Health, Office of Radiation Protection. ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention): A patient received a total of 89 sealed Iodine-125 (half-life of 60 days) seeds implanted on a permanent basis in the prostate, for a total activity of 33.84 millicuries. This was done at Auburn Regional Medical Center (ARMC), Auburn, Washington, on 25 May 2006. The patient was seen / rechecked by ARMC personnel on 26 May 2006. Sometime after that visit, on the same day, he was taken by family members to Good Samaritan Hospital (GSH) in Puyallup, Washington, where he subsequently died of a myocardial infarction. The body was released to a funeral home in Buckley, Washington where it was cremated on 30 May 2006 (about 31 millicuries). The cremains were then boxed up on 31 May 2006 and buried that same day. Although it was reported the patient and the patient's family were given appropriate verbal and written instructions by ARMC; when the patient was treated at GSH it was for the MI only, and had nothing to do with the prior surgical prostate procedure. The family did not, for whatever reason, inform the staff at GSH. The urologists who had treated the patient for the prostate cancer did not work at GSH and had no connection there. Therefore, once the patient died, personnel at GSH had no idea they were also dealing with a radioactive source problem. Personnel at ARMC had no way of knowing of the treatment or death of the patient since it did not occur at their facility or in their city. The RSO for Tacoma Radiation Oncology Center (who provides medical physics support and treatment planning for sealed source therapy to clients such as ARMC and GSH) visited the funeral home on 7 June 2006 and surveyed the crematorium using a meter with a NaI probe. Background was noted at approximately 0.4 mR/hr. Readings of approximately 3.0 mR/hr were noted at the entrance to the retort. A filter in the air exhaust system was noted to be reading approximately 1.0 mR/hr so it was removed for decay and ultimate disposal by GSH. It appears that most retorts operate at 1600 degrees Fahrenheit, or more, and the titanium capsule would melt a few hundred degrees lower than that. The manufacturer confirmed that all seeds had most likely been melted and would not be recovered whole. The crematorium is at this time on standby until the crematorium is declared clean for further use. It appears the most reasonable way to safely handle this cleaning chore is to have a commercial cleaning company, properly informed and equipped, clean and vacuum the retort with ARMC physics personnel in constant attendance to protect workers from any potential radiation hazards and to remove any contaminated material for decay and disposal. This is scheduled to happen 8 June 2006. Notification Reporting Criteria: WAC 246-221-240 Isotope and Activity involved: Iodine 125 / 31 millicuries (at time of cremation) Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): to be determined, likely none. Lost, Stolen or Damaged? (mfg., model, serial number): melted I-125 seeds. Disposition/recovery: clean and hold material for decay Leak test? NA Vehicle: NA Release of activity? Yes Activity and pharmaceutical compound intended: NA Misadministered activity and/or compound received: NA Device (HDR, etc.) Mfg., Model; computer program: I-125 seeds Exposure (intended/actual); consequences: minimal, likely no consequences Was patient or responsible relative notified? Yes Was written report provided to patient? Yes Was referring physician notified? Yes Consultant used? Yes Event Report No.: WA-06-042
This incident was investigated by the WA Department of Health, Office of Radiation Protection and the Crematorium facility was released for use. Notified R4DO (Graves) and NMSS EO (Collins). |
| Where | |
|---|---|
| Auburn Regional Medical Center Auburn, Washington (NRC Region 4) | |
| License number: | WN-M0149-1 |
| Organization: | Wa Division Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+224.97 h9.374 days <br />1.339 weeks <br />0.308 months <br />) | |
| Opened: | Arden Scroggs 15:58 Jun 8, 2006 |
| NRC Officer: | Joe O'Hara |
| Last Updated: | Jun 19, 2006 |
| 42627 - NRC Website | |
Auburn Regional Medical Center with Agreement State | |
WEEKMONTHYEARENS 426272006-05-30T07:00:00030 May 2006 07:00:00
[Table view]Agreement State Agreement State Report - Damaged Sources 2006-05-30T07:00:00 | |