ENS 53965
ENS Event | |
|---|---|
04:00 Mar 29, 2019 | |
| Title | Agreement State Report - Loss of an I-125 Seed |
| Event Description | The following was received from the State of Florida via email:
Received a call from Adventist Health to report the loss of an I-129 seed that was removed from a patient. According to [Adventist Health], the seed was removed on 2/19/2019 and discovered missing on 2/20/2019, all attempts to locate the seed have been unsuccessful. It is believed that the seed was discarded with the medical waste and sent to the incinerator. A preliminary report will be sent to [the Florida Bureau of Radiation Control] as soon as possible, and followed up with the official report from the hospital when their investigation is complete. Florida Incident Number: FL19-047
The following report was received via e-mail: Adventist Health reported the loss of an I-125 seed that was removed from a patient. The seed was removed [from the patient] on Feb. 19th and discovered missing on Feb. 20th, all attempts to locate the seed have been unsuccessful. It is believed that the seed was discarded with the medical waste and sent to the incinerator. There was no adverse outcome in patient care from this incident. The seed was either disposed of in biohazard or normal trash. In either case, the portal monitors would not have measured the radiation emitted from the seed due to the low activity. No personnel or general public exposure would have been significant based upon the low exposure rate and the nature of controlled biohazard waste. The waste was incinerated. No environmental impact is expected. Corrective actions taken as a result of the loss of this source: 1) Surgery will survey the specimen when placed in the bag before sending to imaging. Education on this process has occurred to ensure compliance. 2) X-ray will scan the specimen placed in the bag with a survey meter when obtaining the specimen x-ray, prior to going to pathology. Education on this process has occurred to ensure compliance. 3) Pathology will survey the specimen upon receipt to confirm the seed is present. Reeducation on this process has occurred to ensure compliance. This event was previously reported as a loss of an I-129 seed, which was incorrect. Seed activity: 241 microCuries Notified R1DO (Young) and NMSS Events and ILTAB (via e-mail). 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 | |
|---|---|
| Adventist Health System Daytona, Florida (NRC Region 1) | |
| License number: | 2897-1 |
| Organization: | Florida Bureau Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+12.38 h0.516 days <br />0.0737 weeks <br />0.017 months <br />) | |
| Opened: | Tim Dunn 16:23 Mar 29, 2019 |
| NRC Officer: | Andrew Waugh |
| Last Updated: | Apr 6, 2019 |
| 53965 - NRC Website | |
Adventist Health System with Agreement State | |
WEEKMONTHYEARENS 539652019-03-29T04:00:00029 March 2019 04:00:00
[Table view]Agreement State Agreement State Report - Loss of an I-125 Seed ENS 427212006-07-21T04:00:00021 July 2006 04:00:00 Agreement State Florida Agreement State Notification of Medical Event 2019-03-29T04:00:00 | |