ENS 55409
ENS Event | |
|---|---|
04:00 Aug 26, 2020 | |
| Title | Lost IODINE-125 Seed |
| Event Description | The following information was obtained from the State of North Carolina via email:
On 25 August 2020, an iodine-125 (I-125) seed was implanted into a perirectal mass in a patient for the purpose of localization and excisional biopsy. Following implantation, the Imaging team surveyed the needle and patient with a Geiger-Mueller detector per standard procedure to confirm proper placement of the seed within the mass. In addition, a post-implantation CT scan confirmed the presence of the seed within the mass. The seed and patient data were entered into the on-line 'Seed Tracker' software by the Imaging team per standard procedure. Excision of the tumor containing the seed was planned for the next day, and the patient was discharged home. At the time of surgery on 26 August 2020, the operative team was unable to detect the seed within the mass. Although the absence of the seed was documented in the operative note, the surgical team did not report that unusual occurrence to the Imaging team or the Radiation Safety Division. The specimen, which contained no seed and was not labeled as containing a seed, was sent to Surgical Pathology as a routine specimen and was processed as such. However, the Surgical Pathology team failed to notice that an entry for that patient and seed had been made in the 'Seed Tracker'. The error was not detected until an audit of the information in the 'Seed Tracker' was performed by staff of the Imaging teams and the Radiopharmacy in July 2021. The discrepancy between the 'Seed Tracker' data and the labeling and processing of the specimen as 'non-radioactive' was resolved when the surgical team's operative note was consulted. Because locating the seed would have been unlikely and impractical after 10 months (activity estimated to be 4 microcuries), our efforts were focused on investigating the root causes and identifying corrective actions. Probable disposition of lost material: Based upon the confirmation of seed placement in the perirectal mass by survey and CT scan, and its absence upon excision the following day, the seed most likely migrated out the implantation track and was discharged into the sanitary sewer during a bowel movement. Migration of seeds is uncommon but does occur. In this case, it would not have been noticed by the patient. North Carolina Item Number: NC210013 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 |
| Where | |
|---|---|
| Duke University Medical Center Durham, North Carolina (NRC Region 1) | |
| License number: | 032-0247-4 |
| Organization: | North Carolina Div Of Rad Protectio |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+8553.82 h356.409 days <br />50.916 weeks <br />11.717 months <br />) | |
| Opened: | Ken Bugaj 13:49 Aug 17, 2021 |
| NRC Officer: | Kerby Scales |
| Last Updated: | Aug 17, 2021 |
| 55409 - NRC Website | |
Duke University Medical Center with Agreement State | |
WEEKMONTHYEARENS 562542022-12-01T05:00:0001 December 2022 05:00:00
[Table view]Agreement State Patient Underdose ENS 554092020-08-26T04:00:00026 August 2020 04:00:00 Agreement State Lost IODINE-125 Seed ENS 542822019-09-16T04:00:00016 September 2019 04:00:00 Agreement State Agreement State Report - Medical Event ENS 535912018-09-07T04:00:0007 September 2018 04:00:00 Agreement State Agreement State Report - Administered Dose Lower than Prescribed Dose ENS 525802017-02-24T05:00:00024 February 2017 05:00:00 Agreement State Agreement State Report - Medical Event Due to High Dose ENS 510322014-03-30T04:00:00030 March 2014 04:00:00 Agreement State Agreement State Report - Iodine 125 Seed Left in Patient ENS 463892010-10-22T18:45:00022 October 2010 18:45:00 Agreement State Agreement State Report - Medical Event - Dose Administered in Wrong Location 2022-12-01T05:00:00 | |