ENS 47560
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ENS Event | |
|---|---|
08:00 Dec 21, 2011 | |
| Title | Agreement State Report - Iodine-125 Brachytherapy Seed Missing from Transportation Package |
| Event Description | The following report was received by telephone from the State of Nevada.
A representative of the State of Nevada Radiation Control Program was notified by a call from Cardinal Health and Summerlin Hospital in Las Vegas NV concerning a missing I-125 brachytherapy seed. Summerlin Hospital on or about 12/21/11 transferred 33 Iodine-125 brachytherapy seeds to Cardinal Health for shipment back to Bard Brachytherapy in Illinois. The 33 Iodine-125 seed shipment was packaged and sent by Cardinal Health to Bard via commercial carrier on or about 12/21/11. Upon receipt of the seeds by Bard, the top of the shipping pig was discovered to not be completely sealed. Some of the seeds were outside the pig but within the shipping package. After all the seeds were inventoried, a total of 32 seeds were received by Bard. At this time, one of the seeds appears to be unaccounted for. The missing I-125 seed had an activity of 0.23 milliCuries at the time of shipment. The half-life of Iodine-125 is approximately 60 days. Bard has surveyed the local carrier that transported the shipment to its facility. It has also surveyed the regional facility of the shipping carrier. Cardinal Health and Summerlin are still attempting to confirm the original inventory of seeds was 33. The State of Nevada is continuing its investigation of the missing seed. 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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| Where | |
|---|---|
| Cardinal Health Las Vegas, Nevada (NRC Region 4) | |
| License number: | 03-11-0332-01 |
| Organization: | Nv Div Of Rad Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+201.68 h8.403 days <br />1.2 weeks <br />0.276 months <br />) | |
| Opened: | Adrian Howe 17:41 Dec 29, 2011 |
| NRC Officer: | Bill Huffman |
| Last Updated: | Dec 29, 2011 |
| 47560 - NRC Website | |
Cardinal Health with Agreement State | |
WEEKMONTHYEARENS 573482024-09-27T09:00:00027 September 2024 09:00:00
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Radiopharmaceutical Worker Received >50 Rem to Both Hands ENS 475602011-12-21T08:00:00021 December 2011 08:00:00 Agreement State Agreement State Report - Iodine-125 Brachytherapy Seed Missing from Transportation Package ENS 465662010-12-28T06:00:00028 December 2010 06:00:00 Agreement State Agreement State Report - Transportation Accident Involving Radiopharmaceuticals ENS 464512010-12-02T11:20:0002 December 2010 11:20:00 Agreement State Agreement State Report - Employee Contaminations During Cyclotron Operation ENS 453422009-09-11T09:30:00011 September 2009 09:30:00 Agreement State Agreement State Report - Contaminated Pharmacy Shipment Package ENS 453632009-07-21T04:00:00021 July 2009 04:00:00 Agreement State Agreement State - Potential Extremity Overexposure ENS 443072008-06-13T08:00:00013 June 2008 08:00:00 Agreement State Agreement State Report Involving a Vehicle Transporting Radioactive Material ENS 442642008-06-03T05:00:0003 June 2008 05:00:00 Agreement State Agreement State Report - Radiopharmaceuticals Delivery Vehicle Accident ENS 441362008-04-09T12:00:0009 April 2008 12:00:00 Agreement State Agreement State - Mississippi - Traffic Accident Involving Truck Carrying Tc-99M ENS 441392008-03-19T04:00:00019 March 2008 04:00:00 Agreement State Agreement State - Florida - Missing Dose of Tc-99M ENS 438412007-11-19T15:13:00019 November 2007 15:13:00 Agreement State Agreement State Report - Dose to Wrong Organs ENS 437312007-09-24T05:00:00024 September 2007 05:00:00 Agreement State Agreement State Report Involving an Improper Injection ENS 434322007-05-16T05:00:00016 May 2007 05:00:00 Agreement State Louisiana Agreement State Report - Medical Event Due to Dispensing Error ENS 432012007-02-14T06:00:00014 February 2007 06:00:00 Agreement State Agreement State Report - Dispensing Error for Thallium -201 Dose ENS 429992006-11-16T06:00:00016 November 2006 06:00:00 Agreement State Agreement State - Stolen Truck Containing Radiopharmiceuticals ENS 428582006-09-22T11:00:00022 September 2006 11:00:00 Agreement State Agreement State Report - Traffic Accident Involving a Truck Carrying Radioactive Material ENS 426242006-05-22T05:00:00022 May 2006 05:00:00 Agreement State Agreement State Report - Unsecured Delivery of Radioactive Material ENS 424412006-03-22T08:00:00022 March 2006 08:00:00 Agreement State Agreement State Report - Radiation Exposure ENS 424182006-03-05T06:00:0005 March 2006 06:00:00 Agreement State Agreement State Report - Patient Received Improper Medical Dose ENS 422732006-01-18T06:00:00018 January 2006 06:00:00 Agreement State Agreement State Report of an Extremity Exposure Greater than Limit ENS 422362005-12-29T16:45:00029 December 2005 16:45:00 Agreement State Agreement State Report - Transportation Accident Involving Used Technetium 99M Syringes ENS 422232005-12-22T12:30:00022 December 2005 12:30:00 Agreement State Agreement State Report of Traffic Accident Involving Radioactive Material ENS 418402005-06-26T21:20:00026 June 2005 21:20:00 Agreement State Agreement State - Medical Sources Stolen ENS 414692005-03-08T13:40:0008 March 2005 13:40:00 Agreement State Agreement State Report - Truck Containing Radiopharmaceuticals Stolen in Massachusetts ENS 413512005-01-20T17:00:00020 January 2005 17:00:00 Agreement State Agreement State Report Involving a Pharmacy Spill of Samarium-153 ENS 413062005-01-01T10:00:0001 January 2005 10:00:00 Agreement State Agreement State Report of Truck Crash Resulting in Minor Contamination and Loss of Radiopharmaceutical Vials ENS 412712004-10-25T20:00:00025 October 2004 20:00:00 Agreement State Agreement State Medical Event ENS 409362004-08-09T13:30:0009 August 2004 13:30:00 Agreement State Spill of I-131 Resulting in Contamination ENS 418332004-05-02T04:00:0002 May 2004 04:00:00 Agreement State Agreement State Report Involving a Potential Extremity Overexposure ENS 408482004-02-27T05:00:00027 February 2004 05:00:00 Agreement State Lousiana Agreement State Report - Medical Event ENS 405532004-02-26T21:00:00026 February 2004 21:00:00 Agreement State Agreement State Reports Spill at Nuclear Pharmacy 2024-09-27T09:00:00 | |
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