ENS 53017
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ENS Event | |
|---|---|
04:00 Sep 21, 2017 | |
| Title | Agreement State Report - Post Implant Loss of Iodine-125 Seed |
| Event Description | The following information was received from the State of New York via facsimile:
On September 21, 2017 the Department [New York State Department of Health] was notified that a Best Medical International, Inc., Model #2301 lodine-125 seed used for localization of non-palpable lesions and lymph nodes was lost. On September 18, a patient was implanted with a 125.2 microCurie lodine-125 seed. The seed was verified to be implanted by use of a survey meter. When the patient returned for explant three days later, the iodine-125 seed could not be detected. The licensee surveyed the patient's vehicle, house, laundry, and trash and no radioactivity was detected. The licensee reported placing the seed 'superficially' within the patient and the licensee speculates that the seed may have become dislodged from the patient at some point between the implant and explant. New York Report ID No.: NYDOH-NY-17-08 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 | |
|---|---|
| Not Provided Not Provided, New York (NRC Region 1) | |
| License number: | Not Provided |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+607.13 h25.297 days <br />3.614 weeks <br />0.832 months <br />) | |
| Opened: | Daniel Samson 11:08 Oct 16, 2017 |
| NRC Officer: | Vince Klco |
| Last Updated: | Oct 16, 2017 |
| 53017 - NRC Website | |
Not Provided with Agreement State | |
WEEKMONTHYEARENS 550062020-11-23T04:00:00023 November 2020 04:00:00
[Table view]Agreement State Dosed Incorrect Organ ENS 543982019-11-20T18:00:00020 November 2019 18:00:00 Agreement State Agreement State Report - Iodine 125 Seed Migrated from Implant Location ENS 530172017-09-21T04:00:00021 September 2017 04:00:00 Agreement State Agreement State Report - Post Implant Loss of Iodine-125 Seed ENS 526972017-04-12T04:00:00012 April 2017 04:00:00 Agreement State Agreement State Report - Less than Intended Dose Administered to the Patient ENS 526672017-04-05T04:00:0005 April 2017 04:00:00 Agreement State Agreement State Report - Less than Prescribed Dose Administered to Patient ENS 525932017-03-04T05:00:0004 March 2017 05:00:00 Agreement State Agreement State Report - Missing Iodine 125 Calibration Sources ENS 524732016-12-29T05:00:00029 December 2016 05:00:00 Agreement State Agreement State Report - Medical Event ENS 523042016-10-17T04:00:00017 October 2016 04:00:00 Agreement State Agreement State Report - Medical Underdose ENS 519702016-05-24T04:00:00024 May 2016 04:00:00 Agreement State Agreement State Report - Medical Underdose to the Left Lobe of Liver ENS 519192015-12-02T05:00:0002 December 2015 05:00:00 Agreement State Agreement State Report - Unplanned Contamination Event ENS 513902015-09-10T04:00:00010 September 2015 04:00:00 Agreement State Agreement State Report - Medical Treatment Dose Lower than Prescribed ENS 510992015-05-27T05:00:00027 May 2015 05:00:00 Agreement State Agreement State Report - Lost Iodine-125 Medical Seeds ENS 510372015-04-30T05:00:00030 April 2015 05:00:00 Agreement State Agreement State Report - Ruptured Iodine Seed During Removal ENS 508102015-01-12T05:00:00012 January 2015 05:00:00 Agreement State Agreement State Report - Medical Misadministration During Cancer Treatment ENS 434962007-07-11T06:00:00011 July 2007 06:00:00 Agreement State Agreement State Report - Moisture Gauge Source Disconnected from Cable ENS 433012007-03-07T04:00:0007 March 2007 04:00:00 Agreement State Agreement State Report - Medical Event ENS 468952005-01-01T04:00:0001 January 2005 04:00:00 Agreement State Agreement State Report - Dose Administered >20% Different from Prescribed Dose 2020-11-23T04:00:00 | |
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