ENS 52389

v t e ENS Event
06:00 Nov 17, 2016
Title	Agreement State Report - I-125 Seed Left Inside a Patient
Event Description	Yesterday (November 21, 2016) we [Oklahoma Department of Environmental Quality] were notified by Integris Health (OK-11022-01) that a brachytherapy seed containing 0.1 mCi of I-125 had been lost. The seed was implanted in a patient on November 14 for localization of a non-palpable breast lesion. The tissue was removed on November 17 and sent to pathology. The patient had also had a sentinel node procedure on the same day and received a dose of Tc-99. The licensee believed that the seed had been removed with the specimen. The specimen was sent to the pathology lab on November 18 and showed no radiation when surveyed there. The licensee initiated a search of their facilities at that time. The patient returned to the hospital yesterday for their post-operative evaluation, was again surveyed, and the seed was detected. Yesterday evening, the licensee emailed us that the seed had actually been left in the patient. We are making this notification as a possible medical event. The licensee is performing a dose calculation on the patient. Our investigation is ongoing and we will provide more information as it becomes available. 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.

ENS 52389 +/-
Where
Integris Health Oklahoma City, Oklahoma (NRC Region 4)
License number:	Ok-11022-01
Organization:	Ok Deq Rad Management
Reporting

Agreement State
Time - Person (Reporting Time:+126.28 h5.262 days <br />0.752 weeks <br />0.173 months <br />)
Opened:	Kevin Sampson 12:17 Nov 22, 2016
NRC Officer:	Mark Abramovitz
Last Updated:	Nov 22, 2016
52389 - NRC Website
v • d • e

v t e Emergency Notification System
Integris Health with Agreement State
WEEKMONTHYEAR2016-11-17T06:00:00 [Table view]
[ENS list for Integris Health]

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