On October 5, 2017, Johns Hopkins Outpatient Center, notified the
Maryland Radiological Health Program (RHP) that on October 5, 2017, following a prostate seed implant procedure, the licensee discovered that one (1) seed was unaccounted for. The
Pd-103 seed has an activity of approximately 1.5 milliCuries. The number of seeds implanted into the patient was 42 out of 47 seeds ordered. Four (4) seeds remained in the applicator. This left one (1) seed unaccounted for. Two physicists counted 42 seeds implanted, verified on two separate C-arm images. All personnel were scanned with a
sodium iodide survey meter as they exited the room. All equipment, tables, waste bags, surgical covers, linens, etc. were scanned multiple times. The floor was systematically and methodically scanned, including the patient's Foley bag, with negative results.
The patient will return tomorrow [October 6, 2017] for a follow-up CT and chest x-ray. Radiation Oncology will re-count the seeds. Theragenics Corporation will also be contacted to determine if only 46 seeds were shipped. These seeds are received precalibrated and presterilized.
A reactive inspection will be conducted to investigate this event.
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