Date: 16-21 November 1992

Location: Indiana Regional Cancer Center, Indiana, Pennsylvania, USA

Type of event: radiotherapy accident

Description:

An 82-year-old female patient was undergoing brachytherapy, a type of radiotherapy, at the Indiana Regional Cancer Center. A 3.7-curie iridium-192 source was dislodged from equipment and accidentally left in the patient; this went unrecognized since the staff failed to perform required checks to secure sources. The patient was returned to the nursing home and died 93 hours later due to the radiation injury from the embedded source. The catheter containing the source was removed by the nursing home staff and disposed of as medical waste. The waste disposal company discovered the source during routine checks for radioisotopes. The ensuing Nuclear Regulatory Commission investigation concluded that exposures of 0.034 to 2.57 rem were incurred by 94 individuals, including clinic staff, nursing home staff, nursing home residents and visitors, and waste disposal company employees.

Consequences: 1 fatality.

References:

• Dicus, Greta Joy, 4 April 1997, "Materials safety and regulation," on line, U.S. Nuclear Regulatory Commission [http://www.nrc.gov/reading-rm/doc-collections/commission/speeches/1997/s97-08.html].
• Flynn, D. F., I. Mihalakis, T. Mauceri, and M. R. Pins, Feb. 1993, "Gastrointestinal syndrome after accidental overexposure during radiotherapy," Loss of an Iridium-192 Source and Therapy Misadministration at Indiana Regional Cancer Center, Indiana, Pennsylvania, on November 16, 1992, NUREG-1480, U.S. Nuclear Regulatory Commission (Washington, DC).
• Goans, R. E., and N. Wald, 2005, "Radiation accidents with multi-organ failure in the United States," British Journal of Radiology Supplement, 27:41-46.
• Ortiz, P., M. Oresegun, and J. Wheatley, 2000, "Lessons from major radiation accidents," on line, Internationl Radiation Protection Association [http://www.irpa.net/irpa10/cdrom/00140.pdf].
• Ricks, Robert C., Mary Ellen Berger, Elizabeth C. Holloway, and Ronald E. Goans, 2000, "REAC/TS radiation accident registry: update of accidents in the United States," on line, International Radiation Protection Association [http://www.irpa.net/irpa10/cdrom/00325.pdf].

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