ENS 51596
ENS Event | |
|---|---|
06:00 Nov 17, 2015 | |
| Title | Lost Iodine-125 Seed |
| Event Description | One 180 microCi I-125 seed for breast radioactive seed localization (I-125 RSL) was lost at Brooke Army Medical Center (BAMC) on 17 November 2015.
Loss of the I-125 seed occurred in BAMC Pathology on 17 November 2015 due to lack of training and supervision of new Residents during the removal of the seed while grossing the specimen. Health Physics Service (HPS) was notified and responded to Anatomic Pathology/Histology at approximately 1130 on 20 November. According to events leading up to the loss, the I-125 seed was not removed from the specimen prior to being submitted for sectioning. Typically, RSL seeds are tracked on a BAMC I-125 Seed Tracking Form, which indicates when the seed is removed from the specimen. In this case, the tracking form was completed only to the point of Pathology receiving the specimen with the seed still within. A radiograph illustrating the seed within the specimen was taken on 16 November 2015 in Mammography and delivered with the specimen to Pathology. Due to a lack of supervision and training, [the Pathology Resident] did not verify on the tracking form that the seed had been removed. The I-125 Seed Tracking Form was found incomplete on 20 November 2015 by the RSO [Radiation Safety Officer], who then contacted [the Pathology Resident] and informed the Health Physics personnel. Health Physics personnel immediately responded and performed a survey of the entire Histology suite focusing on all work stations and processing equipment used in the preparation of this specimen; the seed was not located within the Histology suite. According to [the Pathology Resident], the step to verify seed removal was overlooked, and confirmation of the seed's absence with a radiation probe was skipped. Furthermore, the tissue was grossed and submitted entirely for sectioning. Most likely, the seed stuck to the grid and was disposed of as biohazard waste. The biohazard disposal route from Pathology on the 4th floor to the hospital exit passes through radiation monitors located on the fourth floor and in basement utility rooms and the biohazard waste room, but due to the low activity of one I-125 seed in biohazard bag with unknown amount of material the monitors would not alarm. Initial activity of the I-125 RSL seed was 300 microCi on 7 October 2015, and had decayed to 180 microCi on 20 November 2015. Assuming no shielding, an exposure rate of 0.03 mR/hr at 1 meter is to be expected. Personnel are not likely to handle the waste for an extended period of time and the waste was likely incinerated at Stericycle. Steps have been taken since the incident to prevent recurrence. A. Procedure: The grossing staff pathologist will ensure seed disposal via inspection of appropriate paperwork and scanning with appropriate probe rather than verbal assurance. B. Additional training sessions on the use of the NeoProbe and I-125 RSL seed procedure. Based on accounts above, the I-125 seed was left with the specimen during grossing and was then submitted to sectioning and the seed was lost. In addition to ensuring the proper training and SOPs [Standard Operating Procedures] are in place and followed, we will continue to have radiation monitors in place on each floor and the back loading docks of the facility to make certain there is full accountability of the I-125 seeds. The licensee notified NRC Region 4 (Torres). 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 | |
|---|---|
| Brooke Army Medical Center San Antonio, Texas (NRC Region 4) | |
| License number: | 42-01368-01 |
| Organization: | Department Of The Army |
| Reporting | |
| 10 CFR 20.2201(a)(1)(ii) | |
| Time - Person (Reporting Time:+557.8 h23.242 days <br />3.32 weeks <br />0.764 months <br />) | |
| Opened: | Maj. David Byrd 11:48 Dec 10, 2015 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Dec 10, 2015 |
| 51596 - NRC Website | |
Brooke Army Medical Center with 10 CFR 20.2201(a)(1)(ii) | |
WEEKMONTHYEARENS 539922019-03-13T05:00:00013 March 2019 05:00:00
[Table view]10 CFR 20.2201(a)(1)(ii) Lost I-125 Seeds ENS 515962015-11-17T06:00:00017 November 2015 06:00:00 10 CFR 20.2201(a)(1)(ii) Lost Iodine-125 Seed ENS 510582015-05-07T16:11:0007 May 2015 16:11:00 10 CFR 20.2201(a)(1)(ii) Lost Iodine-125 Seed 2019-03-13T05:00:00 | |