ENS 42689
ENS Event | |
|---|---|
09:40 Jun 18, 2006 | |
| Title | Agreement State - Misplaced Source |
| Event Description | At 0634 hrs on June 20, 2006, [the Director of the Texas Department of Health] received a call on the way to the office from the Director of Radiology for Ben Taub General Hospital in Houston, TX. He relayed brief details of a recovered source that was either taken out of a patient or never placed in an after loading appliance utilized for the treatment of a cervical cancer patient. In the words of the Radiation Safety Officer with proper names redacted:
On Sunday, June 18, 2006 at 4:40 am a Cesium-137 source, 3M model 6501(6D6C-CA), serial # 06965, with an activity of approximately 17 mCi [milliCuries] was noted to be missing from a patient who was undergoing a tandem and ovoid implant for cervical cancer. The patient had applicator placement (uterine tandem and two Fletcher ovoids) at Ben Taub General Hospital (BTGH), on Friday 6/16/2006. The Cesium sources (4 in all; 2 in the tandem and 1 each in the ovoid) had been placed in the patient by the Radiation Oncologist at 3:40 pm for a 37 hour4.282407e-4 days <br />0.0103 hours <br />6.117725e-5 weeks <br />1.40785e-5 months <br /> implant. When the right ovoid source was noted to be missing at the time of unloading; the patient, room, Nursing Unit 6B of the hospital, and the route of transport of the sources from the BTGH Radiotherapy Department to the patient's room were surveyed using both a sodium iodide detector and a conventional air-ionization type survey meter by both the Radiation Oncologist and Medical Physicist. The BTGH Radiation Safety Officer was notified at 8:20 am Sunday morning of the apparent missing source. Upon further investigation, it was learned that the bed sheets of the patient had been changed at 3 pm on Saturday, 6/17/2006, and this dirty linen was placed in the linen cart on 6B. It was subsequently taken to a truck at the BTGH loading dock and transported to the Texas Medical Center Laundry facility. On Monday morning, 6/19/06, the director of this facility was contacted and subsequently the facility was surveyed. The Cs-137 source was recovered at 10:30 a.m., from the third floor and transported back to the BTGH Radiotherapy Department using an appropriately shielded container. The names of all the persons who potentially may have come into contact with the Cesium source were obtained and notified. This list included thirty-five [35] individuals of both hospital and laundry services personnel. Upon further review by staff in assembling the documents for the incident file, the attachments to the June 26, 2006 e-mail was examined at 1400hrs on July 7, 2006. At that time DSHS staff realized that this was a lost/found source with quantities >1,000 X Appendix C value requiring immediate reporting to NMED. However, staff reviewed the operational setting and in the absence of the licensee's report demonstrating an exposure exceeding of 100mrem to a member of the public, the incident may not be reportable. Further investigation is on-going. Texas Incident: I-8350 |
| Where | |
|---|---|
| Ben Taub General Hospital Houston, Texas (NRC Region 4) | |
| License number: | 01303 |
| Organization: | Texas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+462.05 h19.252 days <br />2.75 weeks <br />0.633 months <br />) | |
| Opened: | Art Tucker 15:43 Jul 7, 2006 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Jul 7, 2006 |
| 42689 - NRC Website | |
Ben Taub General Hospital with Agreement State | |
WEEKMONTHYEARENS 429652006-11-05T22:00:0005 November 2006 22:00:00
[Table view]Agreement State Texas Agreement State Report - Missing Source ENS 426892006-06-18T09:40:00018 June 2006 09:40:00 Agreement State Agreement State - Misplaced Source 2006-06-18T09:40:00 | |