ENS 51099
ENS Event | |
|---|---|
05:00 May 27, 2015 | |
| Title | Agreement State Report - Lost Iodine-125 Medical Seeds |
| Event Description | The following report was received from the State of Texas via email:
On May 29, 2015, a licensee notified the Agency [Texas Department of State Health Services] that it was unable to locate a package containing approximately 41.2 millicuries of Iodine-125 seeds. The package had been received at the licensee's facility on May 26, 2015, and per the licensee's procedures, it was delivered to the nuclear medicine department and left in the designated area. However, the staff in the nuclear medicine department had been allowed to leave due to a slow schedule. On May 27, 2015, when staff returned, they were unable to locate the package. The licensee conducted a facility wide search. The [licensee's] materials management employee that placed the package in the nuclear medicine department and the housekeeping employee that cleaned the department the previous night were interviewed. The housekeeper reported, [to have] not removed any boxes from the department. The licensee was unable to identify anyone else had entered the department. The facility's waste container had been picked up and taken to the landfill earlier that morning. The licensee checked with the landfill and learned it does have a radiation monitor but the container from the hospital had not set it off. The contents of the container had already been covered over in the landfill. The patient's procedure was canceled and re-scheduled. The licensee has changed its procedures for radioactive material package delivery by the facility's materials management to the nuclear medicine department to prevent reoccurrence. The licensee is continuing its search for the package. An investigation into this event is ongoing. The Agency [Texas Department of State Health Services] has withheld the name of the licensee [and license number and location] in accordance with Texas state law. Further information will be provided as it is obtained in accordance with SA-300. Texas Incident #: I-9317 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 | |
|---|---|
| Not Provided Not Provided, Texas (NRC Region 4) | |
| License number: | NOT PROVIDED |
| Organization: | Texas Dept Of State Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+56.68 h2.362 days <br />0.337 weeks <br />0.0776 months <br />) | |
| Opened: | Karen Blanchard 13:41 May 29, 2015 |
| NRC Officer: | John Shoemaker |
| Last Updated: | May 29, 2015 |
| 51099 - NRC Website | |
Not Provided with Agreement State | |
WEEKMONTHYEARENS 550062020-11-23T04:00:00023 November 2020 04:00:00
[Table view]Agreement State Dosed Incorrect Organ ENS 543982019-11-20T18:00:00020 November 2019 18:00:00 Agreement State Agreement State Report - Iodine 125 Seed Migrated from Implant Location ENS 530172017-09-21T04:00:00021 September 2017 04:00:00 Agreement State Agreement State Report - Post Implant Loss of Iodine-125 Seed ENS 526972017-04-12T04:00:00012 April 2017 04:00:00 Agreement State Agreement State Report - Less than Intended Dose Administered to the Patient ENS 526672017-04-05T04:00:0005 April 2017 04:00:00 Agreement State Agreement State Report - Less than Prescribed Dose Administered to Patient ENS 525932017-03-04T05:00:0004 March 2017 05:00:00 Agreement State Agreement State Report - Missing Iodine 125 Calibration Sources ENS 524732016-12-29T05:00:00029 December 2016 05:00:00 Agreement State Agreement State Report - Medical Event ENS 523042016-10-17T04:00:00017 October 2016 04:00:00 Agreement State Agreement State Report - Medical Underdose ENS 519702016-05-24T04:00:00024 May 2016 04:00:00 Agreement State Agreement State Report - Medical Underdose to the Left Lobe of Liver ENS 519192015-12-02T05:00:0002 December 2015 05:00:00 Agreement State Agreement State Report - Unplanned Contamination Event ENS 513902015-09-10T04:00:00010 September 2015 04:00:00 Agreement State Agreement State Report - Medical Treatment Dose Lower than Prescribed ENS 510992015-05-27T05:00:00027 May 2015 05:00:00 Agreement State Agreement State Report - Lost Iodine-125 Medical Seeds ENS 510372015-04-30T05:00:00030 April 2015 05:00:00 Agreement State Agreement State Report - Ruptured Iodine Seed During Removal ENS 508102015-01-12T05:00:00012 January 2015 05:00:00 Agreement State Agreement State Report - Medical Misadministration During Cancer Treatment ENS 434962007-07-11T06:00:00011 July 2007 06:00:00 Agreement State Agreement State Report - Moisture Gauge Source Disconnected from Cable ENS 433012007-03-07T04:00:0007 March 2007 04:00:00 Agreement State Agreement State Report - Medical Event ENS 468952005-01-01T04:00:0001 January 2005 04:00:00 Agreement State Agreement State Report - Dose Administered >20% Different from Prescribed Dose 2020-11-23T04:00:00 | |