ENS 44488

v t e ENS Event
15:30 Aug 14, 2008
Title	Unaccounted for Iodine-125 Seed Following Implant Procedure
Event Description	On August 14, 2008, a procedure to implant 94 Iodine-125 seeds was performed on a patient at the Missouri Baptist Medical Center. A quantity of 100 seeds was taken from inventory for this procedure. Upon completion of the procedure a count of the non-implanted seeds revealed that only 5 seeds were remaining, not six as expected. The missing seed had an activity of 0.493 mCi on the date of implant. The licensee performed a survey of the operating room on August 14, 2008, and a CT of the patient. The missing seed could not be accounted for. 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.

ENS 44488 +/-
Where
Missouri Baptist Medical Center St. Louis, Missouri (NRC Region 3)
License number:	24-11128-02
Organization:	Missouri Baptist Medical Center
Reporting

10 CFR 20.2201(a)(1)(ii)
Time - Person (Reporting Time:+766.75 h31.948 days <br />4.564 weeks <br />1.05 months <br />)
Opened:	Richard Keys 14:15 Sep 15, 2008
NRC Officer:	Dan Livermore
Last Updated:	Sep 15, 2008
44488 - NRC Website
v • d • e

v t e Emergency Notification System
Missouri Baptist Medical Center with 10 CFR 20.2201(a)(1)(ii)
WEEKMONTHYEAR2008-08-14T15:30:00 [Table view]
[ENS list for Missouri Baptist Medical Center]

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