AW: [ RadSafe ] Old Reports

Fri Mar 31 05:20:31 CST 2006

 FATALITY - Brachytherapy  source wire had broken - Indiana, PA 
Loss of an iridium-192 source and therapy misadministration 
.
In 1992, a waste disposal company reported finding a radiation source in waste. The NRC investigation revealed that in November, 1992 a clinic in Indiana, PA treated an elderly patient with high dose brachytherapy using a 3.7 Ci Ir-192 source. The treatment was terminated early because of equipment problems. Unbeknownst to the operators, the source wire had broken and the source remained in the patient. A radiation survey of the patient at the end of the treatment to confirm that the source was safely secured was required but was not performed.   
The patient went from the clinic to a nursing home where she died 5 days later. The catheter (containing the source) was removed by nursing home personnel and disposed of as biohazardous waste. The source was discovered during routine radiation surveillance of waste by the waste disposal company. The additional dose received by the patient was a contributing factor in the patient's death. As many as 94 persons were exposed to the source including clinic staff, nursing home staff, residents and visitors and waste disposal company employees. Doses to the public ranged from 0.034 to 2.57 rem
. 
Reference \USNRC, Loss of an Iridium-192 Source and Therapy Misadministration at Indiana Regional Cancer Center Indiana, Pennsylvania, on November 16, 1992. NUREG -1480, February 1993     

Jose Julio Rozental
joseroze at netvision.net.il
Israel
.----- Original Message ----- 
From: <BLHamrick at aol.com>
To: <franz.schoenhofer at chello.at>; <TGaglierd at achd.net>; <radsafe at radlab.nl>
Sent: Friday, March 31, 2006 10:01 AM
Subject: Re: AW: [ RadSafe ] Old Reports

> 
> It was Ir-192, and the hospital was in Indiana, Pennsylvania.  I  haven't 
> searched at NRC for the report on this incident, but I expect it is  there 
> somewhere.
>  
> Barbara
>  
> In a message dated 3/30/2006 10:32:36 P.M. Pacific Standard Time,  
> franz.schoenhofer at chello.at writes:
> 
> However  I do not believe that you will find anywhere a report on a I-193
> implant,  because this radionuclide simply does not exist, and especially no
> "Inidana  Co PA Hospital" might be known. 
> 
> 
> 
> 
> _______________________________________________
> You are currently subscribed to the RadSafe mailing list
> 
> Before posting a message to RadSafe be sure to have read and understood the RadSafe rules. These can be found at: http://radlab.nl/radsafe/radsaferules.html
> 
> For information on how to subscribe or unsubscribe and other settings visit: http://radlab.nl/radsafe/
> 