ENS Event | |
|---|---|
20:00 Sep 11, 2013 | |
| Title | Lost Brachytherapy Medical Source |
| Event Description | The licensee reported that a brachytherapy source/seed was lost after completion of a medical procedure. After the seed was removed from the patient, the device was improperly placed in the rack for sterilization and cleaning and it is believed the seed was lost as part of this cleaning process. Normally, the device would have been placed in a surgical bowl and moved to a flash chamber for seed recovery. The seed was a Best Double Walled I-125 seed with a 204 microcurie source, model #2301.
There was no harm to the patient or exposures to other personnel. The licensee is continuing their investigation and will provide additional information when it becomes available. 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 | |
|---|---|
| Kalispell Regional Medical Center Kalispell, Montana (NRC Region 4) | |
| License number: | 25-15463-01 |
| Organization: | Kalispell Regional Medical Center |
| Reporting | |
| 10 CFR 20.2201(a)(1)(ii) | |
| Time - Person (Reporting Time:+116.83 h4.868 days <br />0.695 weeks <br />0.16 months <br />) | |
| Opened: | Andrea Vanterpool 16:50 Sep 16, 2013 |
| NRC Officer: | John Shoemaker |
| Last Updated: | Sep 16, 2013 |
| 49350 - NRC Website | |
Kalispell Regional Medical Center with 10 CFR 20.2201(a)(1)(ii) | |
WEEKMONTHYEARENS 493502013-09-11T20:00:00011 September 2013 20:00:00
[Table view]10 CFR 20.2201(a)(1)(ii) Lost Brachytherapy Medical Source 2013-09-11T20:00:00 | |