Event Notification Report for May 31, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/30/2007 - 05/31/2007

** EVENT NUMBERS **

General Information or Other	Event Number: 43390
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT Licensee: HOLY CROSS HOSPITAL Region: 1 City: SILVER SPRINGS State: MD County: License #: MD-31-001-03 Agreement: Y Docket: NRC Notified By: RAY MANLEY HQ OPS Officer: MARK ABRAMOVITZ	Notification Date: 05/25/2007 Notification Time: 13:01 [ET] Event Date: 05/24/2007 Event Time: 15:40 [EDT] Last Update Date: 05/25/2007
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JAMES TRAPP (R1) SANDRA WASTLER (FSME)

Event Text

AGREEMENT STATE REPORT - Pd-103 SOURCE BROKEN OPEN

The State provided the following information via facsimile:

"Called to report an incident at Holy Cross Hospital. At 1540 hours, on 5/24/07, in room 11 of the operating room of the hospital, the Licensee ruptured a 3.2 mCi Palladium-103 seed while conducting a patient implant therapy. Preliminary licensee evaluation indicates that the Mick Applicator jammed and failed to advance. Efforts to free the device may have led to the seed fracture. The patient therapy was halted after 60 of the 83 seeds (given in the written directive) were successfully implanted. The Oncologist has indicated that the 60 seeds implanted were adequate for successful therapy and no additional seeds would be administered. Licensee followed radiation spill procedures and radiation surveys conducted by licensee RSO showed radioactive material contamination on the Mick Applicator and surrounding absorbent chucks. Contaminated materials have been controlled and stored in nuclear the medicine department. Smears of adjacent OR surfaces and floor were negative for contamination. The OR was released at about 1900 hours that day. The licensee has notified the manufacturer of the incident. Licensee will send initial written report by CBD 5/29/07 with follow-up detailed report within 30 days."

Maryland Radioactive Material License: MD-31-001-03

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.

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