AGREEMENT STATE REPORT - REPORT OF LOST I-125 SEED DURING MEDICAL PROCEDURE
"Nebraska Department of Health and Human Services, Office of Radiological Health was notified on December 21, 2018 at 8:50 am CST by the Radiation Safety Officer (RSO) from Regional West Medical Center (Nebraska license 21-01-03) that one I-125 seed is lost and still missing at this time. The I-125 seed was part of a manual brachytherapy procedure that involved one hundred permanently implanted I-125 seeds in the patient's prostate. The procedure occurred in a surgery suite at approximately 9 am MST, the patient was then transported to a recovery room and then to a CT suite to confirm the placement of the seeds at approximately 12:19 pm MST. During the review of the CT, the licensee observed that only ninety nine seeds were implanted. The licensee then conducted a search for the missing I-125 seed.
"During the search of the missing I-125 seed on December 13, 2018, licensee staff surveyed the surgical suite and recovery room of the patient. The licensee staff were not able to find the missing seed. During the survey, licensee staff also questioned the nursing staff and it was noted that a nurse emptied a catheter bag into a toilet shortly following the completion of surgery. Licensee staff believe that the missing I-125 seed may have been flushed and disposed in the sanitary sewage system.
"The missing I-125 seed was a Bard Medical product, serial number 7815544SO, containing 283 uCi and was one of many seeds preloaded into a needle to be injected into the patient. On December 13, 2018 at 9:30 am CST, the RSO was contacted to report the search results in the adjacent hallways, the CT suite, and if possible, any sewage holding areas. The RSO has dispatched staff to conduct a new search of all areas and transport beds that the patient was in and in contact areas. The RSO expects this to be completed later in the day of 12/21/2018.
"The State is awaiting the results of this new survey and will be following up with the licensee and US NRC."
Nebraska Report: NE-18-0009
* * * UPDATE AT 1721 EST ON 02/07/2019 FROM LARRY HARISIS TO JEFF HERRERA * * *
The following update was received from the Nebraska Department of Health and Human Services (DHHS) via email:
"On 01/16/2019, Nebraska DHHS Office of Radiological Health staff arrived at the licensee's facility. Discussions, reenactments, radiological surveys, and presentations were performed and given to assess if the I-125 seed was disposed of in the sanitary system. A review of the licensee's training of oncology staff and nursing personnel, policies and procedures for specific seed implantation for oncology and nursing staff, and interviews of all involved personnel were completed.
"It was determined that all 100 I-125 seeds were implanted into the patient as ordered and the bladder was verified as emptied by a cystoscope after removing an inflated balloon to prevent seeds from entering the bladder. After the inflatable balloon device was removed from the patient, a seed near the urethra was dislodged and entered the urethra then into a urinary catheter bag. When the oncology personnel arrived at the patient's recovery room, they noticed that the urinary catheter bag was abnormally low. Oncology personnel found that a nurse in the recovery room emptied the urinary catheter bag without approval from Oncology personnel, inadvertently disposing of the seed in a sink in the recovery room. Oncology personnel surveyed the surgical suite, recovery room, and sink with no results above background. A review of the policies and procedures of radioactive seed implantation with the nursing staff was also completed.
"The licensee's implementation of corrective measures to prevent a reoccurrence will be reviewed on the next inspection."
Notified the R4DO (Werner) and NMSS Events (via email).
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.
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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |