ENS Event | |
|---|---|
06:00 Nov 21, 2012 | |
| Title | Agreement State Report - Medical Event |
| Event Description | The following information was obtained from the Commonwealth of Kentucky via facsimile:
Kentucky Radiation Health Branch was notified on November 21, 2012 by the [licensee's] Medical Physicist, that a medical event occurred during the final hours of a gynecological radiation implant using Cs-137. The 40 hour4.62963e-4 days <br />0.0111 hours <br />6.613757e-5 weeks <br />1.522e-5 months <br /> procedure was scheduled to end today at 0915 CST. Upon arrival at 0910 to remove the applicators, the patient stated [that] shortly after 0600 she felt something had moved or urination or gel had come out of her. As the Medical Physicist pulled back the patient's gown, she saw the packing from the implant completely out of the patient. The top of the packing was approximately 1cm from the perineum. The sources were quickly removed from the applicators and put in a shielded transport container. The Medical Physicist's initial dose estimate to the skin on the patient's thigh and surrounding area is close to 450 cGy based on the applicator being out for 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br />. There were a total of 5 sources used, 3 in the tandem all had the same activity (96.11 cGy*cm2/hr) and one in each ovoid, both having an activity of 29.63 cGy*cm2/hr. Radiation survey measurements of the applicators, patient, and room were below background. The RSO, patient, and prescribing physician are aware of the event that occurred and a follow-up is scheduled. The State will continue to keep NRC informed of the status of our investigation. KY Event Report ID# KY120014 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. |
| Where | |
|---|---|
| Norton Suburban Hospital Louisville, Kentucky (NRC Region 1) | |
| License number: | 202-099-26 |
| Organization: | Kentucky Dept Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+9.15 h0.381 days <br />0.0545 weeks <br />0.0125 months <br />) | |
| Opened: | Marissa Velez 15:09 Nov 21, 2012 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Nov 21, 2012 |
| 48530 - NRC Website | |
Norton Suburban Hospital with Agreement State | |
WEEKMONTHYEARENS 509672015-03-12T05:00:00012 March 2015 05:00:00
[Table view]Agreement State Agreement State Report - Treatment Underdose ENS 485302012-11-21T06:00:00021 November 2012 06:00:00 Agreement State Agreement State Report - Medical Event ENS 441932008-04-28T05:00:00028 April 2008 05:00:00 Agreement State Kentucky Agreement State Report - Medical Event - Patient Received Incorrect Dose of I-131 2015-03-12T05:00:00 | |