Late on 8/25/15, the [Chief Physicist] was informed that the
I-125 seed count in storage does not reconcile with the Written Directives and the pathology log. The storage vial is one seed short. Instead of 30 seeds, there are only 29 seeds. Also there is a non-radioactive marker/clip in the storage container along with 29
Iodine-125 seeds. All seeds are of nominal activity of 0.3 mCi. The
lead container housing the sources was brought down to Radiation Oncology source storage room on 8/26/2015.
So far our findings are as follows:
Radiation survey of the pathology lab was performed by the pathology lab supervisor. Survey revealed no presence of radioactivity. Radiation survey of the stored tissue specimens for these cases revealed no radioactivity. [Licensee staff] reviewed the radiographs of each tissue specimen and the count was 30 seeds. It would seem that the pathology assistant mistook the marker/clip to be an iodine seed and put it in storage container and the actual seed somehow got discarded as hazardous waste, in spite of the documented procedure to survey everything which comes in contact with specimen to be surveyed with Geiger counter. By reviewing the radiographs of each specimen we have ruled out the possibility that a source was left in the patient. On 8/26/2015, another independent radiation survey of the Pathology Lab was performed by Nuclear Medicine using a scintillation detector and once again no seed was found.
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