ENS 51037
ENS Event | |
|---|---|
05:00 Apr 30, 2015 | |
| Title | Agreement State Report - Ruptured Iodine Seed During Removal |
| Event Description | The following was received from the State of Texas via email:
On May 4, 2015, licensee's Radiation Safety Officer (RSO) reported to the Agency [Texas Department of State Health Services] that he had been notified today that on Thursday, April 30, 2015, a physician had ruptured an I-125 seed during removal from a patient. The seed was used for localization in a breast treatment procedure. The seed activity was 357 microCuries at the time of treatment on 4/30/15. The seed was identified as leaking after removal and in a container in the pathology department. The physician had screened the patient with a probe in the tissue/lesion and no radioactivity was found. No overexposure to the patient or doctor had occurred. The RSO stated he was preparing a full detailed report. Further information will be provided in accordance with SA300 guidelines. Texas Incident # I-9310 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.
This report is retracted based on the following: More complete information was obtained from the licensee. The seed covering was damaged by the physician during excision of tissue from patient. The patient was thoroughly checked following the excision (standard procedure) and there was no radiation detected. There was radioactivity detected in the excised tissue by pathology after seed was removed from the tissue. The licensee identified and remediated all contamination and managed processing of tissue to prevent further contamination. No aspect of the event met any reporting criteria. It has been determined this was not a reportable event. Notified R4DO (Taylor) and NMSS Events Notification via email. |
| Where | |
|---|---|
| Not Provided Temple, Texas (NRC Region 4) | |
| Organization: | Texas Dept Of State Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+102.77 h4.282 days <br />0.612 weeks <br />0.141 months <br />) | |
| Opened: | Irene Casares 11:46 May 4, 2015 |
| NRC Officer: | Dong Park |
| Last Updated: | May 20, 2015 |
| 51037 - 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 | |