ENS Event | |
|---|---|
05:00 Dec 6, 2016 | |
| Title | En Revision Imported Date 5/13/2019 |
| Event Description | EN Revision Text: AGREEMENT STATE REPORT - I-125 APPLICATOR LEAK TEST FAILURE
The following was received via e-mail: During a Wisconsin Department of Health Services inspection a previously unreported event was discovered. The date of the event is still being determined. While performing a manual brachytherapy procedure, the Mick applicator became jammed and the licensee switched to a different applicator to finish the procedure. Following the procedure, the [Radiation Safety Officer] RSO wiped the jammed device and found contamination so several I-125 seeds were isolated and held for decay in storage." This indicates that the device failed a leak test, which is a reportable event.
On December 6, 2016, while performing a manual brachytherapy procedure, a Mick applicator became jammed when the oncologist was attempting to insert a seed. The radiation oncologist removed the Mick applicator and switched to an extra Mick applicator with a different cartridge of seeds. A surgeon continued implanting seeds with the physicist to finish the procedure. Meanwhile, the radiation oncologist forcefully extracted the cartridge from the jammed Mick applicator. This was when the physicist/RSO believed that a seed was ruptured. Following the procedure, the RSO took the Mick applicator to the nuclear medicine hot lab and wiped the device and cartridge. The RSO found contamination on the seeds/cartridge so thirteen I-125 seeds (.333mCi each) were isolated and held for decay in storage in the hot lab. There is no indication of contamination in the operating room surveys or any expected uptake by the patient. Notified R3DO (Stoedter) and NMSS Events (via email). 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 | |
|---|---|
| St Nicholas Hospital Sheboygan, Wisconsin (NRC Region 3) | |
| License number: | 117-1302-01 |
| Organization: | Wisconsin Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+21058.78 h877.449 days <br />125.35 weeks <br />28.846 months <br />) | |
| Opened: | Joseph Ross 14:47 May 2, 2019 |
| NRC Officer: | Jeffrey Whited |
| Last Updated: | May 10, 2019 |
| 54041 - NRC Website | |
St Nicholas Hospital with Agreement State | |
WEEKMONTHYEARENS 540412016-12-06T05:00:0006 December 2016 05:00:00
[Table view]Agreement State En Revision Imported Date 5/13/2019 ENS 406872004-04-13T20:30:00013 April 2004 20:30:00 Agreement State Agreement State Report - Accidental Shipment of Radioactive Material 2016-12-06T05:00:00 | |