The following report was received from the Commonwealth of
Kentucky via email:
[The licensee] reported the loss of a I-125 localization seed (lsoAid Advantage, Model IAI-125A). On 1/19/16, the licensee discovered the number of seeds in storage did not match the number recorded. After the licensee conducted an investigation, they believe the seed was lost when it was transferred from the vial, pathology puts them in, to the Cidex storage/decontamination vial. The seeds in the vial had been placed there between 12/21/15 and 1/18/16. As part of the investigation the licensee verified that all seeds were removed from patients during that time and the hot lab was thoroughly searched.
They [the licensee] believe the I-125 seed was most likely disposed of in the trash and taken to landfill with other waste from the hospital. The licensee reported the missing seed came from one of the three orders, lot #39858, 0.147 mCi as of 1/19/16, lot #39809, 0.128 mCi as of 1/19/16, or lot #39111, 0.075 mCi as of 1/19/16. Corrective actions include retraining Nuclear Medicine Techs in the handling of radioactive breast seeds, including stressing the importance of surveying all material to verify that the seed was placed in the Cidex vial and not lost in the surrounding area.
Kentucky Event Report ID No.: KY160001
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