Event Notification Report for July 01, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/30/2015 - 07/01/2015
Non-Agreement State
Event Number: 51220
Rep Org: OAKWOOD HOSPITAL
Licensee: OAKWOOD HOSPITAL
Region: 3
City: DEARBORN State: MI
County:
License #: 21-04515-01
Agreement: N
Docket:
NRC Notified By: TALJIT SANDHU
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: OAKWOOD HOSPITAL
Region: 3
City: DEARBORN State: MI
County:
License #: 21-04515-01
Agreement: N
Docket:
NRC Notified By: TALJIT SANDHU
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/10/2015
Notification Time: 13:18 [ET]
Event Date: 07/01/2015
Event Time: 00:00 [EDT]
Last Update Date: 07/10/2015
Notification Time: 13:18 [ET]
Event Date: 07/01/2015
Event Time: 00:00 [EDT]
Last Update Date: 07/10/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
SEALED I-125 SOURCE DAMAGED DURING PATHOLOGY EXAMINATION
A breast implant of an I-125 seed had been performed followed by a lumpectomy. The lump with the implanted seed was sent to the pathology lab for analysis. During the analysis, the Pathology assistant cut through the I-125 seed. No contamination was noted on the counter top and a thyroid scan of the Pathology assistant was negative.
"1) The source was placed in the leaded container which would not allow any I-125 to escape and release any radioactivity any longer.
"2) There was no radioactive material left on the countertop which was further verified by a wipe test.
"3) A thyroid bioassay was performed on the Pathology assistant working on the specimen and the results were negative.
"4) On 7/9/15 a wipe test of the source revealed that the source integrity was compromised indicated by elevated counts on the wipe compared to the background (4900 dpm vs 120, indicating an activity of approximately 1.5 micro Curie). This indicates that surface of the solid source is contaminated.
"5) [The licensee] will also contact the vendor to find out if the source can be returned to them (since the source is in a sealed shielded container)."
A breast implant of an I-125 seed had been performed followed by a lumpectomy. The lump with the implanted seed was sent to the pathology lab for analysis. During the analysis, the Pathology assistant cut through the I-125 seed. No contamination was noted on the counter top and a thyroid scan of the Pathology assistant was negative.
"1) The source was placed in the leaded container which would not allow any I-125 to escape and release any radioactivity any longer.
"2) There was no radioactive material left on the countertop which was further verified by a wipe test.
"3) A thyroid bioassay was performed on the Pathology assistant working on the specimen and the results were negative.
"4) On 7/9/15 a wipe test of the source revealed that the source integrity was compromised indicated by elevated counts on the wipe compared to the background (4900 dpm vs 120, indicating an activity of approximately 1.5 micro Curie). This indicates that surface of the solid source is contaminated.
"5) [The licensee] will also contact the vendor to find out if the source can be returned to them (since the source is in a sealed shielded container)."
Agreement State
Event Number: 51252
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: RADIOTHERAPY CLINICS OF GEORGIA
Region: 1
City: CONYERS State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: RADIOTHERAPY CLINICS OF GEORGIA
Region: 1
City: CONYERS State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/22/2015
Notification Time: 15:20 [ET]
Event Date: 07/01/2015
Event Time: 00:00 [EDT]
Last Update Date: 07/22/2015
Notification Time: 15:20 [ET]
Event Date: 07/01/2015
Event Time: 00:00 [EDT]
Last Update Date: 07/22/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - VAGINAL CATHETER SLIPPED DURING TREATMENT
The following report was received via e-mail:
"An incident has come to light at [the licensee's] Conyers clinic. A patient was treated with a vaginal cylinder at the beginning of July, 2015. The treatment was delivered in 3 fractions. On a recent follow-up exam, the patient presented with a single mark on the skin of the upper inner thigh on both legs. The radiation oncologist felt these marks were consistent with radiation dermatitis. A review of the patient's treatment plan and treatment records showed no errors had occurred.
"[The licensee's] current thinking is that the only plausible explanation is that the catheter which contains the source wire was not securely locked inside the vaginal cylinder and partially slipped out during treatment.. If this occurred, the most proximal dwell position could have fallen on the skin of the upper thigh.
"[The Georgia Radioactive Materials Program] is continuing to investigate."
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 report was received via e-mail:
"An incident has come to light at [the licensee's] Conyers clinic. A patient was treated with a vaginal cylinder at the beginning of July, 2015. The treatment was delivered in 3 fractions. On a recent follow-up exam, the patient presented with a single mark on the skin of the upper inner thigh on both legs. The radiation oncologist felt these marks were consistent with radiation dermatitis. A review of the patient's treatment plan and treatment records showed no errors had occurred.
"[The licensee's] current thinking is that the only plausible explanation is that the catheter which contains the source wire was not securely locked inside the vaginal cylinder and partially slipped out during treatment.. If this occurred, the most proximal dwell position could have fallen on the skin of the upper thigh.
"[The Georgia Radioactive Materials Program] is continuing to investigate."
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.