The following was received by the Commonwealth of
Massachusetts via fax:
On 8/22/2013, Brigham and Women's Hospital (BWH) was involved in a discrepancy in the contents of a shipment of I-125 brachytherapy seeds. The shipment was labeled to contain 71 seeds (as ordered), plus 4 seeds to be used for QC purposes. Upon opening, in preparation for administration, a count of the sources revealed only 70 of the 71 expected therapy seeds.
Immediate recount and subsequent survey & investigation of the area, packaging and container showed no indication of the presence of the 71st seed. There was also no evidence of contamination detected.
BWH does not believe the 71st seed was delivered.
Meanwhile, the supplier, Bard Brachytherapy, Inc.'s (BBI) investigation indicates that the 71st seed was shipped to BWH.
The expected 71st seed was a Bard Brachytherapy, Inc., model 125I containing 0.561 mCi (with an apparent activity of 0.330 mCi), with a reference date of 8/17/2013.
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