ENS 52551
ENS Event | |
|---|---|
05:00 Jan 18, 2017 | |
| Title | Lost Iodine-125 Implant Seed |
| Event Description | In compliance with 10 CFR 20.2201(a), this report serves as notification of the loss of licensed material under West Virginia University Hospital Broad Scope License 47-23066-02.
On January 18, 2017, the Radiation Safety Department discovered that one Iodine-125 seed used in a Radioactive Seed Localization (RSL) procedure was missing. The seed in question had been implanted on November 8, 2016 and contained 241 microCuries of I-125. The patient had surgery to excise the specimen with the seed on the same day as implantation. The specimen went to the Breast Care Center for imaging and then to the Pathology gross room where the seeds are removed and placed into plastic vials to await pick up by Radiation Safety staff. Radiation Safety staff documented that the seed in question plus 3 others were picked up from the gross room on November 9, 2016 and taken to the radioactive waste storage area. The seed was discovered missing on January 18, 2017 during preparation of a return shipment of seeds to the manufacturer. WVU Radiation Safety promptly investigated the cause of the incident and performed thorough radiation surveys in the Pathology gross room, radioactive waste storage area, and specimen blocks in Pathology, however all surveys were indistinguishable from background. WVU Hospital feels it is likely that the seed was extracted from the specimen in the gross room but was never placed into the plastic vial and subsequently ended up discarded in the gross room waste. During pick up by Radiation Safety, the seed was falsely identified by a visual verification as being present in the plastic vial. A blue plastic spacer, which comes preloaded in the syringe with the seed, may have been mistakenly identified as the seed due to its similar size and shape. WVU Hospital has instituted corrective actions to include more intense radiation surveys and better documentation of those surveys to prevent a future occurrence. In compliance with 10 CFR 20.2201(b), please expect a written report within the next 30 days for more details regarding this incident. 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 | |
|---|---|
| West Virginia University Hospital Morgantown, West Virginia (NRC Region 1) | |
| License number: | 47-23066-02 |
| Organization: | West Virginia University Hospital |
| Reporting | |
| 10 CFR 20.2201(a)(1)(ii) | |
| Time - Person (Reporting Time:+681.08 h28.378 days <br />4.054 weeks <br />0.933 months <br />) | |
| Opened: | Nasser Razmianfar 14:05 Feb 15, 2017 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Feb 15, 2017 |
| 52551 - NRC Website
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West Virginia University Hospital with 10 CFR 20.2201(a)(1)(ii) | |
WEEKMONTHYEARENS 525512017-01-18T05:00:00018 January 2017 05:00:00
[Table view]10 CFR 20.2201(a)(1)(ii) Lost Iodine-125 Implant Seed 2017-01-18T05:00:00 | |