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Event Notification Report for February 9, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/06/2004 - 02/09/2004

** EVENT NUMBERS **


40502

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Hospital Event Number: 40502
Rep Org: MERCY HEALTH SYSTEM
Licensee: MERCY HEALTH SYSTEM
Region: 1
City: DARBY State: PA
County:
License #: 37-00993-05
Agreement: N
Docket:
NRC Notified By: JOHN BABU
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 02/03/2004
Notification Time: 14:05 [ET]
Event Date: 01/23/2004
Event Time: [EST]
Last Update Date: 02/06/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
Person (Organization):
JOHN KINNEMAN (R1)
JOHN HICKEY ()

Event Text

HIGH BACKGROUND READINGS FOUND IN STERILIZATION WATER USED TO STERILIZE THE SEEDS AND CARTRIDGE PRIOR TO USAGE.

The licensee reported that during the completion of a prostate implant a higher than background reading was measured in the sterilization water used to sterilize the seeds and the cartridge prior to the implant. The licensee had two extra seeds left over after the implant, so they returned them to the manufacturer along with a sample of the sterilization water to be analyzed. The manufacturer suspects that one of the seeds may have been a leaking, but that has not yet been verified. A bioassay was also performed on the staff involved with the implant and only the physicist had a higher than background reading. The patient was also given a bioassay, but since they have never done this to a patient, there was no data to compare with.

* * * UPDATE AT 0930 EST ON 2/06/04 FROM J. BABU TO GOTT * * *

The licensee reported that a second patient also had a higher thyroid bioassay but his urine sample tested negative. The licensee is continuing with their investigation.

Notified NMSS (Psyk) and R1DO (Kinneman)

* * * UPDATE AT 1431 EST ON 2/06/04 FROM J. BABU TO A. COSTA * * *

Detectable contamination was found upon surveying the left over seeds (12 to 18) from the second patient. Two swipes were taken of all seeds together and the first swipe indicated 809 counts per minute and the second swipe indicated 1689 counts per minute. Background readings was 4 counts per minute. The contamination was localized to the cartridges and seeds. The appropriate areas of the Hospital were surveyed and no detectable contamination was found. The licensee intends to keep the leaking iodine seeds in storage for decay and future disposal.

Notified NMSS (Hickey) and R1DO (Kinneman)

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