Licensee notified NRC that they have been performing an inventory of their
I-125 brachytherapy seeds from 8/26/03 until 12/07/04. In September, the licensee discovered 4 seeds were missing along with a
lead container. The licensee conducted a thorough search and interviewed hospital personnel that had access or used the
brachytherapy seeds for patient treatment. Using a calculated activity range of 0.224 - 0.368 millicuries per seed with a possible decay factor of 4 half lives would give an estimated total remaining activity of 0.09 millicuries. As a preventive measure against future losses the licensee has placed a locked container in the Nuclear Medicine Hot Lab, and the licensee has restricted access to the locked container to only the lab physicist.
- * * UPDATE 1120 EST ON 12/9/04 FROM DR. FERRER TO S. SANDIN * * *
The following information was submitted by the licensee via fax:
On the last quarter, we did an inventory for disposal of our Institution storage of brachytherapy seeds I-125 used for therapy in prostate carcinoma.
All seeds that were not used we gathered for disposal. Upon taking a visual inventory of all the seeds, 4 seeds were missing.
A thorough inventory of 32 seeds was done for the storage period, from August 26, 2003 to September 10, 2004. And immediately preventive measures were taken.
Prevention of reoccurrence - Immediately a locked container was placed in the storage area - Nuclear Medicine Hot Lab. The personnel of brachytherapy were required to place seeds inside the locked container. Our physicist will be the only authorized individual allowed to remove the un-used seeds. This will minimized the number of people that will handle the seeds.
We underwent a thorough search and interview the related personnel, from OR personnel, nurse staff, brachytherapy and nuclear medicine staff. This process took approximately 60 days. During the process we also found out that a lead container was missing and we re-started the searching process.
We calculated the dose range of 0.224 mCi / seed to 0.368 mCi / seed and with a possible decay factor of 4 half lives - for an approximately total activity of 0.09 mCi.
The incident was reported on December 08, 2004 ( 12:04 PM - EST).
Notified R1DO (Anderson) and NMSS (Essig)
- * * UPDATE 0930 EST ON 12/23/04 FROM DR EDUARDO PASCUAL TO S.SANDIN * * *
During remodeling, the four (4) missing I-125 seeds were found in a lead container inside the hot lab.
Notified R1DO (Conte) and
NMSS (Essig).