ENS 51979
ENS Event | |
|---|---|
04:00 Apr 21, 2016 | |
| Title | Agreement State Report - Missing Source |
| Event Description | The following information was received by the State of Ohio via email:
On 4/21/2016 in OR [Operating Room] 11, during seed loading, the dosimetrist noticed that one seed was missing from the transferring stylet as he was transferring the seeds to the loading needle. He immediately notified the physicist in the room. The physicist then checked the sterile area around the cartridge with a survey meter and picked up radiation reading by the luer - lock hub of the cartridge. The physicist assumed that the source had fallen in the sterile towel under the cartridge and determined loading should continue, and they will retrieve the dislodged seed after all needles have been loaded. After all needles were loaded and while implantation was still in progress the physicist and the dosimetrist went to retrieve the dislodged seed but they were not able to locate it. They resurveyed the spot where it was and there was no radiation detected. The physicist emptied the cartridge to verify the number of seeds remaining in the cartridge and the count was as stated in the loading summary. The dislodged seed was missing. To prevent a recurrence, surgical drapes will be used to cover the area under and around the cartridge/loading area instead of sterile hand towels. This would make it easier to identify any seed that may have fallen out during loading. Loose/broken seed(s) will be placed in the lead pig immediately. If there is a dislodged/loose seed that could not be recovered immediately, the physicist will ensure that everyone leaving the room is surveyed. Licensee has previously observed that I-125 seeds are prone to static buildup and have the tendency to cling to plastic, glass walls, and other surfaces. Most likely, the lost seed was swept up and discarded with normal trash. Based on the relatively low activity and low energy of the I-125 seed and measured background readings in the operating room, there was no radiation exposure to personnel or members of the public due to this loss. Source/Radioactive Material: Sealed source brachytherapy Manufacturer: Theragenics Model Number: AgX100 Radionuclide: I-125, 0.000382 Ci Ohio Item Number: OH160006 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 | |
|---|---|
| Akron General Medical Center Akron, Ohio (NRC Region 3) | |
| License number: | 02120780000 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1043.57 h43.482 days <br />6.212 weeks <br />1.429 months <br />) | |
| Opened: | Stephen James 15:34 Jun 3, 2016 |
| NRC Officer: | Dong Park |
| Last Updated: | Jun 3, 2016 |
| 51979 - NRC Website | |
Akron General Medical Center with Agreement State | |
WEEKMONTHYEARENS 530712017-11-06T05:00:0006 November 2017 05:00:00
[Table view]Agreement State Agreement State Report - Dose Greater than 50 Rem Delivered at a Site Not Intended for Treatment ENS 519802016-04-26T04:00:00026 April 2016 04:00:00 Agreement State Agreement State Report - Missing Source ENS 519792016-04-21T04:00:00021 April 2016 04:00:00 Agreement State Agreement State Report - Missing Source ENS 488392013-03-19T04:00:00019 March 2013 04:00:00 Agreement State Agreement State Report - Y-90 Sir-Sphere Under Dose of 87% ENS 486782013-01-15T05:00:00015 January 2013 05:00:00 Agreement State Agreement State Report - Misplacement of Brachytherapy Source During Medical Treatment ENS 431922006-09-27T05:00:00027 September 2006 05:00:00 Agreement State Agreement State Report - Potential Medical Event ENS 427292006-07-10T04:00:00010 July 2006 04:00:00 Agreement State Agreement State Report - Medical Overdose 2017-11-06T05:00:00 | |