On July 22, 2013, it was discovered that one
I-125 0.5 mCi prostate implant seed from a procedure that took place on July 10, 2013, was unaccounted for. Cartridges are assumed to be preloaded with 100 seeds with delivery documentation attesting to the count.
Fluoroscopic x-rays confirmed that seventy two (72) I-125 seeds were implanted in a patient following brachytherapy prostate seed implantation using a Nucletron seed Selectron implantation system on July 10, 2013.
During the initial seed calibration process one (1) seed was disposed into a sterile pig. The implant went smoothly except at one point where due to patient movement three (3) seeds were ejected into a sterile pig.
On July 22, 2013, the medical physicist unloading the seeds from the cartridge found 23 seeds which was 1 less than expected. Surrounding hallways, rooms, and the implant robotic equipment along with the equipment storage area and sterilization areas were surveyed but no additional seeds were discovered.
No foul play is suspected and no unusual levels of radiation have been detected from the operating room or radiation oncology staff.
As a corrective action the licensee will x-ray incoming seed cartridges to take a physical count of the seeds prior to the procedure. Immediately following the implant procedures seed cartridges will be removed from the delivery system and a second x-ray image will be acquired to perform another physical inventory. Images will be retained for record keeping.
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
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