ENS Event | |
|---|---|
06:00 Apr 19, 2005 | |
| Title | Equipment Failed to Function as Designed |
| Event Description | The following information was provided by the State via facsimile:
On Wednesday, April 19, 2005 while loading a Pd-103 seed into the Mick applicator, the applicator jammed. When the operating room technician attempted to get the seed loose, the seed broke. This spread a small amount of radioactive contamination onto the table, which was cleaned up by the RSO and dosimetrist. The applicator was found to be contaminated. It was put in a plastic bag, placed behind lead shielding and locked in the Nuclear Medicine hot lab. The activity of the Pd-103 seed was 1.578 mCi (millicuries). According to the licensee, there was no overexposure, contamination, or intake of radiation by anyone present in the operating room. The patient was treated, as per the prescription after borrowing a Mick applicator from another hospital. The licensee notified DHFS on April 20, 2005. The licensee also contacted their consultant and their MIC applicator distributor regarding the event. A replacement applicator is being sent and the contaminated applicator will be allowed to decay before servicing. The licensee has developed, an action plan for this event based on possible causes: 1. Look into the possibility of having the MIC applicator on a preventative maintenance schedule. 2. Change the sterilization procedure such that central supply does the cleaning of the applicator, not the OR technician. 3. Set up a 'core' group of OR technicians who are involved in their procedure, and document their education. A voluntary MedWatch form was sent in to the FDA. Wisconsin Radiation Protection Section plans on investigating this event. State Event Report ID # 24. |
| Where | |
|---|---|
| Aurora Baycare Medical Center Green Bay, Wisconsin (NRC Region 3) | |
| License number: | 009-1017-01 |
| Organization: | Wisconsin Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+57.08 h2.378 days <br />0.34 weeks <br />0.0782 months <br />) | |
| Opened: | Mike Welling 15:05 Apr 21, 2005 |
| NRC Officer: | Chauncey Gould |
| Last Updated: | Apr 21, 2005 |
| 41620 - NRC Website | |
Aurora Baycare Medical Center with Agreement State | |
WEEKMONTHYEARENS 535122018-07-17T05:00:00017 July 2018 05:00:00
[Table view]Agreement State Agreement State Report - Total Dose Delivered Differed from Prescribed Dose by Greater than 20 Percent ENS 416202005-04-19T06:00:00019 April 2005 06:00:00 Agreement State Equipment Failed to Function as Designed ENS 410082004-08-31T19:00:00031 August 2004 19:00:00 Agreement State Wisconsin Agreement State Report: Source Failed to Retract 2018-07-17T05:00:00 | |