The following is an excerpt from the 30 day report submitted from George
Washington University Hospital:
"On Tuesday, 11/7/2017, one of the pathologists' assistants completed the first seed case of the new week. After placing the seed in the vial which included the prior week's seeds, she counted only 10 seeds. However, there should have been 11; e.g. 10 from the previous week plus the new one from the current week.
Radiation safety confirmed that there were 10 seeds in the vial. Since only 10 lot numbers were written on the vial, this suggests that only 10 seeds were ever placed in the vial (as opposed to 11 being put in the vial, and one of them falling out at some point.)
Radiation safety confirmed that there were 11 flow sheets. Each flow sheet was initialized by a pathologists' assistant that the seed had been recovered and stored in the cabinet. This suggests that one of the pathologists' assistants was distracted and signed the sheet without placing the seed in the vial as per procedure.
The pathology laboratory was surveyed by two individuals from the Radiation Safety Office. The surveys covered all areas of the lab including the work stations, sinks, floors, waste specimens, desks, and storage cabinets. The seed was not located.
The licensed material that has been lost is a single I-125 seed, made by IsoAid for the localization of nonpalpable breast lesions. The seed is a sealed source approximately 5 mm in length. It had a nominal activity of 200 microCi on October 24, 2017.
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