The following information was received from the
New York State Department of Health (
NYS DOH) via facsimile:
The source was a seed source for Breast Localization Procedures. The medical procedure occurred on July 12, 2013. A tissue specimen was removed from a patient. The localization seed was identified and removed from the specimen post-surgery. The seed was not returned to the Nuclear Medicine Department per institute policy, which initiated a facility search for the missing RAM [radioactive material]. Immediate actions included conducting extensive facility area surveys for several weeks. The source was declared officially lost on August 29, 2013. The root cause involved a failure to follow the facility policy. The seed was allowed to become lost, after it had been properly identified. Corrective actions involve an incident review with the pertinent staff and an in-service refresher training for all staff. The facility has been informed by NYS DOH that this event should have been reported immediately on July 12, 2013.
Manufacturer, Best Medical International, Inc., Model No. 2301 I-125, Activity, 140 microCuries.
New York State Report ID No. NY-13-05
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