The State provided the following information via email:
On 3/27/07, licensee reports being unable to locate a single Bard STM 1251 prostate seed containing 0.35 millicuries of Iodine-125 (60-day half-life) soon after a 130-seed (120 stranded seeds and 10 single seeds) medical procedure. This single titanium cylindrical capsule measures 0.8 mm (~0.03 inch) in diameter and 4.5 mm (~0.18 inch) in length (see Sealed Source Registry No. IL-1074-S-101-S). The last known location of the seed was in an operating room within the licensee's facility in Springfield, MA.
The licensee conducted an extensive search of its facilities as described in its written report dated April 9, 2007. The licensee assumes the seed is lost at this point in time.
In order to prevent recurrence, the licensee implemented updated seed counting and inventory control procedure changes and assignment responsibilities.
Cause description: Inconsistent use of seed well container. All 10 single seeds were placed in one well instead of placing one seed in each of ten wells within container.
Corrective action: Updated seed counting, inventory control procedure changes, and assignment responsibilities.
Massachusetts Event Docket Number: 04-6969
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.