Event Notification Report for November 29, 2005

AGREEMENT STATE REPORT INVOLVING A BROKEN I-125 BRACHYTHERAPY SEED

The following information was received via facsimile:

"NY-06-003

"Broken I-125 brachytherapy seed. (NYS DOH Internal Tracking No. 421)

"New York law prohibits the release of any identities in cases of medical events. Therefore the facility name, etc., is not contained in this report.

"RSO reported a broken I-125 source from a prostate seed implant on 11/29/05. The cartridge/source jammed in the applicator and a source was ruptured. All fragments were recovered in the rinse of the applicator and the patient did not have any seed fragments implanted. The written report stated: 90 seeds were ordered, 74 were implanted, 16 unused seeds were recovered (15 intact, one ruptured). The Mick applicator is a model 200-TP. The seeds were GE Healthcare Medi-physics supplied by Oncura Inc. The apparent activity per seed was 0.47 mCi. The radiation oncologist who performed the procedure is experienced (500+ cases). He stated that during the procedure the applicator jammed several times and that he was required to remove seeds from the applicator. It was probably during that process that the seed was ruptured and the loose seeds fell to the table. The medical physicist, upon going to the operating room to retrieve the unused seeds identified two seeds had become loose, one of which was damaged (appeared shorter than the others). A radiological survey indicated that no contamination was present on instruments or the area used for the implant. The inner contents of the broken seed, a silver rod, were recovered. Measurements indicate that the activity remained with the rod rather than being spread around/causing contamination. Bioassay measurements, thyroid and urine, were performed on the patient, physicist and RSO, all with negative results. All unused seeds were placed into the decay in storage program.

"This event did not constitute a misadministration because the number of seeds implanted was as per the treatment plan, and there is no evidence that a leaking (ruptured) seed was implanted. New applicators were ordered and placed into service."

MEDICAL EVENT INVOLVING ADMINISTRATION OF LESS THAN THE PRESCRIBED DOSE

On 11/22/05 a female patient undergoing treatment for cervical cancer received the third fraction of a five (5) fraction treatment plan using a HDR Brachytherapy source. Each fraction was scheduled to deliver 600 cGy to the intended treatment site for a total delivered dose of 3000 cGy. During the third treatment, the delivered dose was 200 cGy, instead of 600 cGy, due to a miscalculation in the distance factor. The treating physician does not believe there will be any adverse effects upon the patient.

POTENTIAL OVEREXPOSURE DUE TO SURGICAL REMOVAL OF PROSTATE WITH SEED IMPLANTS

During surgery to remove a patient's prostate gland, the surgeon announced that there were radioactive seed implants present. The surgeon warned surgical staff in the operating room after the surgery commenced to don lead apron shielding and the prostate gland was covered with a lead apron. The prostate was placed in a plastic container submerged in 5 inches of water in a 5 gallon container with the lead apron over the container based on a consultant's recommendation. The container is in an area with limited access and labeled as a radiation hazard. The hospital does not have a nuclear medicine department or any devices to measure radioactivity. The seed implants were supposedly implanted 90 days ago at a hospital in California with approximately a 30 day half life. The hospital will be ordering a lead shipping container for proper disposal later.

FAULTY SWITCH RENDERED CRITICALITY ACCIDENT ALARM SYSTEM INOPERABLE

"At 0845 CST, on 11/29/2005 the C-337 process building Criticality Accident Alarm System (CAAS) was being tested when a building horn control switch in C-300 Central Control Facility which supplies voltage to actuate the building CAAS evacuation horns was found to not be properly made up. This switch caused the building CAAS horns not to sound when a cluster was actuated. The test which revealed this problem, was the initial
'as found' test, which means the failure most likely occurred prior to today's testing. The C-337 CAAS system is a TSR system which is required to be operable in the current operating mode unless LCO actions are in place. The C-337 CAAS system was last tested on 11/05/2005 and indications are that the switch problem has existed since that time.

"During testing the CAAS alarm was received in C-300, but the evacuation horns did not automatically sound. Per procedure if a criticality alarm had occurred the C-300 operator would have actuated the horn switch manually which would have sounded the evacuation horns. To ensure that not only the C-337 switch was properly repaired, but also to verify all other building horn control switches were in the proper state, a plant wide LCO was implemented and switch outputs were checked to verify the proper voltage output."

The NRC Senior Resident has been notified of this event.