Event Notification Report for July 16, 2007
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/15/2007 - 07/16/2007
EVENT NUMBERS
43539
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
General Information or Other
Event Number: 43539
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: GUNDERSEN LUTHERAN MEDICAL CENTER
Region: 3
City: LACROSSE State: WI
County:
License #: 063-1121-01
Agreement: Y
Docket:
NRC Notified By: LEOLA DEKOCK
HQ OPS Officer: JOHN MacKINNON
Licensee: GUNDERSEN LUTHERAN MEDICAL CENTER
Region: 3
City: LACROSSE State: WI
County:
License #: 063-1121-01
Agreement: Y
Docket:
NRC Notified By: LEOLA DEKOCK
HQ OPS Officer: JOHN MacKINNON
Notification Date: 07/31/2007
Notification Time: 15:40 [ET]
Event Date: 07/16/2007
Event Time: 12:00 [CDT]
Last Update Date: 08/27/2007
Notification Time: 15:40 [ET]
Event Date: 07/16/2007
Event Time: 12:00 [CDT]
Last Update Date: 08/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
STEVE ORTH (R3)
DENNIS RATHBUN (FSME)
STEVE ORTH (R3)
DENNIS RATHBUN (FSME)
AGREEMENT STATE REPORT FROM WISCONSIN - LOSS OF TWO PALLADIUM-103 SEEDS
RSO telephoned DHFS July 31, 2007.
"The RSO notified DHFS by telephone of the possible loss of two Pd-103 implant seeds. The two seeds were unaccounted for following a July 16, 2007 prostate seed implant procedure.
"During the procedure, the Physicist was making the strands using the BARD QuickLink system. About half way through the case he made a relatively long link. When the authorized User tried to load this link it was easily traveling through the implant needle so he retracted it and emptied the entire strand on the OR table backwards through the needle. A new link was made and properly implanted into the patient. Because they needed to use nearly all the ordered seeds for the procedure, the Physicist attempted to take apart the problem link using a pair of tweezers. This required some force to separate the links and seeds. While doing this at least two of the links separated and 'flew' off the table. The past experience with seeds falling in the operating room was that they were relatively easy to find immediately post procedure with the survey meter, so they completed the implant. The on-going inventory indicated there would be 5 leftover seeds. Multiple surveys of the operating room resulted in the recovery of 3 seeds. Surveys of all bed linens were conducted, no additional seeds were located."
The patient will be returning to the facility for routine post implant CT imaging. The implant seed count will be repeated at that time.
Event Report ID No.: WI070015
* * * RETRACTION ON 08/27/07 AT 1005 EDT FROM LEOLA DEKOCK VIA EMAIL TO MACKINNON * * *
"DHFA has received additional information from the licensee. The patient returned to the facility for routine post implant imaging. The implant seed count was repeated at that time. The seed count performed at the time of the implant indicated 115 seeds had been implanted. The additional imaging has identified the presence of 117 seeds."
R3DO (J. Lara) & FSME (C. Flannery) notified.
THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.
RSO telephoned DHFS July 31, 2007.
"The RSO notified DHFS by telephone of the possible loss of two Pd-103 implant seeds. The two seeds were unaccounted for following a July 16, 2007 prostate seed implant procedure.
"During the procedure, the Physicist was making the strands using the BARD QuickLink system. About half way through the case he made a relatively long link. When the authorized User tried to load this link it was easily traveling through the implant needle so he retracted it and emptied the entire strand on the OR table backwards through the needle. A new link was made and properly implanted into the patient. Because they needed to use nearly all the ordered seeds for the procedure, the Physicist attempted to take apart the problem link using a pair of tweezers. This required some force to separate the links and seeds. While doing this at least two of the links separated and 'flew' off the table. The past experience with seeds falling in the operating room was that they were relatively easy to find immediately post procedure with the survey meter, so they completed the implant. The on-going inventory indicated there would be 5 leftover seeds. Multiple surveys of the operating room resulted in the recovery of 3 seeds. Surveys of all bed linens were conducted, no additional seeds were located."
The patient will be returning to the facility for routine post implant CT imaging. The implant seed count will be repeated at that time.
Event Report ID No.: WI070015
* * * RETRACTION ON 08/27/07 AT 1005 EDT FROM LEOLA DEKOCK VIA EMAIL TO MACKINNON * * *
"DHFA has received additional information from the licensee. The patient returned to the facility for routine post implant imaging. The implant seed count was repeated at that time. The seed count performed at the time of the implant indicated 115 seeds had been implanted. The additional imaging has identified the presence of 117 seeds."
R3DO (J. Lara) & FSME (C. Flannery) notified.
THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.