Event Notification Report for June 09, 2001
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/08/2001 - 06/09/2001
EVENT NUMBERS
38151
General Information or Other
Event Number: 38151
Rep Org: COLORADO DEPT OF HEALTH
Licensee: BOLDER COMMUNITY HOSPITAL
Region: 4
City: BOLDER State: CO
County:
License #: 262-01
Agreement: Y
Docket:
NRC Notified By: JACOBI (BY FAX)
HQ OPS Officer: CHAUNCEY GOULD
Licensee: BOLDER COMMUNITY HOSPITAL
Region: 4
City: BOLDER State: CO
County:
License #: 262-01
Agreement: Y
Docket:
NRC Notified By: JACOBI (BY FAX)
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 07/18/2001
Notification Time: 15:30 [ET]
Event Date: 06/09/2001
Event Time: 00:00 [MDT]
Last Update Date: 07/18/2001
Notification Time: 15:30 [ET]
Event Date: 06/09/2001
Event Time: 00:00 [MDT]
Last Update Date: 07/18/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAVID GRAVES (R4)
SUSAN FRANT (NMSS)
DAVID GRAVES (R4)
SUSAN FRANT (NMSS)
AGREEMENT STATE REPORT - LEAKING SEALED SOURCE
The following is taken from a faxed report:
"We have recently experienced an incident resulting in the compromising of the shielding around an Iodine-125 prostate implant seed (sealed source). This report is filed per the requirements of RH 458
"On June 5, 2001, during the course of an I-125 seed implant of a patient's prostate gland an Iodine-125 seed which was thought to have been implanted was instead withdrawn with the implant plunger back into a position partly in the implant applicator and partly in the seed cartridge. This seed position will not allow the cartridge to be removed normally from the implant applicator. A GM counter (thin end window) survey was performed over that section of the implant applicator but the presence of the seed was not detected. The cartridge was then forcefully removed from the applicator. The applicator was rinsed into a stainless steel basin to remove blood clots that were present. The routine survey at the end of the procedure indicated that a seed was present in this washbasin. A bent seed was found in a blood clot. When the seed was removed from the basin, a survey of the basin indicated that the water was also contaminated. It was concluded that the shielding around the seed had been compromised.
"The contents of the rinse basin were poured into a plastic container that could be sealed. All equipment, which had come in contact with the seeds, was surveyed and cleaned until wipe tests demonstrated that removable contamination had been reduced to less than 200 dpm. The sealed plastic container containing the contaminated liquid, and all of the cleaning materials were placed in our long-term waste storage facility for decay. Absorbent material was added to this container on July 11th to soak up any remaining liquid and eliminate any potential spill hazard over the two years (10 half-lives) this container will be in storage.
"The two individuals most closely involved in extracting the seed cartridge and performing the cleanup were given thyroid bioassay exams in the week immediately following the incident. Those exams were negative. The patient was given the same exam approximately one month following the procedure that indicated an uptake of 0.2 ± 0.09 µCi corrected to the day of the implant. If this uptake is real and not the result of radiation scatter from his active prostate seed implant (87 seeds, 22.3 mCi on the day of the thyroid scan), this would result in a radiation dose to the thyroid of not more that 0.8 cGy. This radiation dose has no clinical significance.
"Corrective Actions: This incident occurred because the applicator plunger, which most likely had a blood clot adhering at the point normally in contact with the iodine-125 seed, extracted the seed previously pushed into the prostate gland. The seed, believed to have been implanted, instead came to rest across the space between the applicator body and the seed cartridge. A GM survey of the applicator body and cartridge combination failed to detect the presence of the seed. The seed was damaged when the cartridge was forcefully withdrawn.
"This incident could have been averted using the following procedure:
1. Assume that any cartridge jam is caused by an unaccounted for I-125 seed.
2. Remove the implant needle from the applicator body. (If there is believed to be only one seed involved in the jam, the applicator body may be surveyed by directing the sensitive portion of the GM detector down the barrel of the applicator previously occupied by the implant needle. The GM detector may not be sensitive enough to detect radiation though the sides of the applicator body.)
3. Place the body of the applicator with the cartridge still in place, into the rinse pan.
4. Advance the plunger slowly through the seed cartridge until the seed is visible and can be rinsed away from the body of the applicator. (This may requite lifting the cartridge plunger to allow the applicator plunger past such that it can traverse the full extent of the cartridge.) If the cartridge is not empty the seed causing the jam will be pushed out by another seed so two seeds will deposit in the rinse basin.
5. Withdraw the applicator plunger completely and remove the seed cartridge normally.
6. NEVER forcefully remove a seed cartridge!
"All individuals involved In this incident have reviewed this procedure."
The following is taken from a faxed report:
"We have recently experienced an incident resulting in the compromising of the shielding around an Iodine-125 prostate implant seed (sealed source). This report is filed per the requirements of RH 458
"On June 5, 2001, during the course of an I-125 seed implant of a patient's prostate gland an Iodine-125 seed which was thought to have been implanted was instead withdrawn with the implant plunger back into a position partly in the implant applicator and partly in the seed cartridge. This seed position will not allow the cartridge to be removed normally from the implant applicator. A GM counter (thin end window) survey was performed over that section of the implant applicator but the presence of the seed was not detected. The cartridge was then forcefully removed from the applicator. The applicator was rinsed into a stainless steel basin to remove blood clots that were present. The routine survey at the end of the procedure indicated that a seed was present in this washbasin. A bent seed was found in a blood clot. When the seed was removed from the basin, a survey of the basin indicated that the water was also contaminated. It was concluded that the shielding around the seed had been compromised.
"The contents of the rinse basin were poured into a plastic container that could be sealed. All equipment, which had come in contact with the seeds, was surveyed and cleaned until wipe tests demonstrated that removable contamination had been reduced to less than 200 dpm. The sealed plastic container containing the contaminated liquid, and all of the cleaning materials were placed in our long-term waste storage facility for decay. Absorbent material was added to this container on July 11th to soak up any remaining liquid and eliminate any potential spill hazard over the two years (10 half-lives) this container will be in storage.
"The two individuals most closely involved in extracting the seed cartridge and performing the cleanup were given thyroid bioassay exams in the week immediately following the incident. Those exams were negative. The patient was given the same exam approximately one month following the procedure that indicated an uptake of 0.2 ± 0.09 µCi corrected to the day of the implant. If this uptake is real and not the result of radiation scatter from his active prostate seed implant (87 seeds, 22.3 mCi on the day of the thyroid scan), this would result in a radiation dose to the thyroid of not more that 0.8 cGy. This radiation dose has no clinical significance.
"Corrective Actions: This incident occurred because the applicator plunger, which most likely had a blood clot adhering at the point normally in contact with the iodine-125 seed, extracted the seed previously pushed into the prostate gland. The seed, believed to have been implanted, instead came to rest across the space between the applicator body and the seed cartridge. A GM survey of the applicator body and cartridge combination failed to detect the presence of the seed. The seed was damaged when the cartridge was forcefully withdrawn.
"This incident could have been averted using the following procedure:
1. Assume that any cartridge jam is caused by an unaccounted for I-125 seed.
2. Remove the implant needle from the applicator body. (If there is believed to be only one seed involved in the jam, the applicator body may be surveyed by directing the sensitive portion of the GM detector down the barrel of the applicator previously occupied by the implant needle. The GM detector may not be sensitive enough to detect radiation though the sides of the applicator body.)
3. Place the body of the applicator with the cartridge still in place, into the rinse pan.
4. Advance the plunger slowly through the seed cartridge until the seed is visible and can be rinsed away from the body of the applicator. (This may requite lifting the cartridge plunger to allow the applicator plunger past such that it can traverse the full extent of the cartridge.) If the cartridge is not empty the seed causing the jam will be pushed out by another seed so two seeds will deposit in the rinse basin.
5. Withdraw the applicator plunger completely and remove the seed cartridge normally.
6. NEVER forcefully remove a seed cartridge!
"All individuals involved In this incident have reviewed this procedure."