Event Notification Report for March 30, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/29/2014 - 03/30/2014
EVENT NUMBERS
51032
Agreement State
Event Number: 51032
Rep Org: NORTH CAROLINA DEPT OF HHS
Licensee: DUKE UNIVERSITY MEDICAL CENTER
Region: 1
City: RALEIGH State: NC
County:
License #: 0247-4
Agreement: Y
Docket:
NRC Notified By: DAVID CROWLEY
HQ OPS Officer: DANIEL MILLS
Licensee: DUKE UNIVERSITY MEDICAL CENTER
Region: 1
City: RALEIGH State: NC
County:
License #: 0247-4
Agreement: Y
Docket:
NRC Notified By: DAVID CROWLEY
HQ OPS Officer: DANIEL MILLS
Notification Date: 05/01/2015
Notification Time: 19:10 [ET]
Event Date: 03/30/2014
Event Time: 00:00 [EDT]
Last Update Date: 05/01/2015
Notification Time: 19:10 [ET]
Event Date: 03/30/2014
Event Time: 00:00 [EDT]
Last Update Date: 05/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - IODINE 125 SEED LEFT IN PATIENT
The following was received from the State of North Carolina via email:
"During a recent facility inspection at Duke University Medical Center (License# 0247-4), it was discovered that a lost I-125 seed (National NMED Item #140177) was actually found a couple months later still in the patient's breast tissue. The seed was intended for radioactive seed localization (RSL) of a breast lesion and thought to be excised with the targeted tissue during surgery.
"Events as follows:
-Seed was implanted to patient with 213 uCi on 1/23/2014.
-Discovered missing by licensee on 2/27/2014.
-Reported lost to NC on 3/21/2014.
-Found in patient 3/30/2014, no update given to NC.
-Removed from patient breast on 4/1/2014.
"As of 5/1/2015, the licensee maintains that there was only 12.5 rads received to the 250g of breast tissue and not above the 50 rem for medical event reporting. This is currently under investigation by the NC Radioactive Materials Branch as our preliminary numbers suggest the breast tissue dose could be as high as 66 rem in the maximally exposed 100g of tissue.
"The licensee is not concerned with overall adverse reaction to the patient health due to them receiving a subsequent external beam radiation treatment that deposited between 300-1100 rads to the affected breast.
"This possible medical event is tied to the former local NMED Incident# NC 140014 where the source was lost, and it is now being tracked by a new local NMED Incident# NC 150010."
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.
The following was received from the State of North Carolina via email:
"During a recent facility inspection at Duke University Medical Center (License# 0247-4), it was discovered that a lost I-125 seed (National NMED Item #140177) was actually found a couple months later still in the patient's breast tissue. The seed was intended for radioactive seed localization (RSL) of a breast lesion and thought to be excised with the targeted tissue during surgery.
"Events as follows:
-Seed was implanted to patient with 213 uCi on 1/23/2014.
-Discovered missing by licensee on 2/27/2014.
-Reported lost to NC on 3/21/2014.
-Found in patient 3/30/2014, no update given to NC.
-Removed from patient breast on 4/1/2014.
"As of 5/1/2015, the licensee maintains that there was only 12.5 rads received to the 250g of breast tissue and not above the 50 rem for medical event reporting. This is currently under investigation by the NC Radioactive Materials Branch as our preliminary numbers suggest the breast tissue dose could be as high as 66 rem in the maximally exposed 100g of tissue.
"The licensee is not concerned with overall adverse reaction to the patient health due to them receiving a subsequent external beam radiation treatment that deposited between 300-1100 rads to the affected breast.
"This possible medical event is tied to the former local NMED Incident# NC 140014 where the source was lost, and it is now being tracked by a new local NMED Incident# NC 150010."
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.