ENS 44949
ENS Event | |
|---|---|
04:00 Mar 31, 2009 | |
| Title | Agreement State Report - Lost I-125 Seed |
| Event Description | The following information was received from the State of Florida via fax:
Cardinal Health working under Mayo Clinic license lost one I-125 seed. Sterilization room and adjoining spaces and personnel were surveyed. It is speculated that the source entered the internal plumbing of the sterilizer. The pipes are of sufficient thickness to prevent external detection. It is surmised by Mayo RSO that Cardinal Health personnel did not follow procedure. RSO estimates that remaining activity as of 31 Mar 2009 is 150 micro Ci's [original activity 300 micro Ci's], with no increased exposure to Cardinal Health staff. Mayo Clinic will work with Cardinal Health staff to modify procedure to ensure source cannot escape vial or tray during sterilization. In addition, retraining will be conducted with all Cardinal health staff involved. Any further investigation is referred to Materials and Licensing. This office will take no further action on this incident. The Florida Incident Number for this event is FL09-030. 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. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source |
| Where | |
|---|---|
| Mayo Clinic Jacksonville, Florida (NRC Region 1) | |
| License number: | 1812-3 |
| Organization: | Florida Bureau Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+28.8 h1.2 days <br />0.171 weeks <br />0.0395 months <br />) | |
| Opened: | Steve Furnace 08:48 Apr 1, 2009 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Apr 1, 2009 |
| 44949 - NRC Website | |
Mayo Clinic with Agreement State | |
WEEKMONTHYEARENS 566712023-08-09T04:00:0009 August 2023 04:00:00
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