ENS 57166
ENS Event | |
|---|---|
04:00 May 27, 2024 | |
| Title | Lost Brachytherapy Seeds |
| Event Description | The following information was provided by the South Carolina Department of Health and Environmental Control via phone and email:
The South Carolina Department of Health and Environmental Control was notified on June 5, 2024, at 1130 EDT via telephone that a medical event had occurred at Medical University Hospital Authority d/b/a Medical University of South Carolina (licensee). The licensee reported that a patient had undergone a manual brachytherapy procedure (Gammatile Implantation) resulting in the implantation of forty (40) Cs-131 seeds in the patients brain on May 16, 2024. The licensee reported that the patient had been released and then returned on May 27, 2024, due to medical complications. Seven (7) of the forty (40) Cs-131 seeds were removed from the patient on May 27, 2024, and the remaining thirty three (33) seeds were removed from the patient on May 30, 2024. The licensee is reporting that on May 27, 2024, the seven (7) Cs-131 seeds that were removed from the patient are lost or missing. The other thirty three (33) seeds are accounted for. SC Event Number: 240003 The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The exact source strength of the lost seeds was not provided, however, the licensee reported that the quantity was greater than 10 times but less than 1000 times the 10CFR20 Appendix C value for Cs-131.
The following information was provided by the South Carolina Department of Health and Environmental Control via email: For the seven (7) Cs-131 seeds that were lost on May 27, 2024, the licensee is reporting the estimated activity at the time of removal and loss was approximately 2.5 millicuries per seed and approximately 17.5 millicuries total. Notified R1DO (Bickett), NMSS Events Notification (email), ILTAB (email). 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 | |
|---|---|
| Medical University - South Carolina Charleston, South Carolina (NRC Region 1) | |
| License number: | SC-RML-081 |
| Organization: | Sc Dept Of Health & Env Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+244.42 h10.184 days <br />1.455 weeks <br />0.335 months <br />) | |
| Opened: | Adam Gause 08:25 Jun 6, 2024 |
| NRC Officer: | Adam Koziol |
| Last Updated: | Jun 7, 2024 |
| 57166 - NRC Website | |
Medical University - South Carolina with Agreement State | |
WEEKMONTHYEARENS 571662024-05-27T04:00:00027 May 2024 04:00:00
[Table view]Agreement State Lost Brachytherapy Seeds ENS 571652024-05-27T04:00:00027 May 2024 04:00:00 Agreement State Brachytherapy Misadministration 2024-05-27T04:00:00 | |