ENS 54045

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v t e ENS Event
04:00 May 2, 2019
Title	Agreement State Report - I-125 Seed Lost
Event Description	The following information was received via e-mail: On 5/1/19 a patient had two [radioactive seed localization] RSL seeds [200 microCuries; I-125] implanted. The same patient returned the following day for an explant procedure. At that time, it was discovered that one seed was missing from the patient. The licensee confirmed through recorded imaging, consultation with the surgeon, patient surveys, and detailed surveys of the implant site and the explant site that the most likely area where the seed was lost was somewhere in between when the patient left the implant site and returned to the explant site the following day. North Carolina Radioactive Materials Branch has started an investigation that is ongoing at this time. This event is reportable per 20.2201(a)(1)(ii) - Lost, stolen, or missing licensed material in a quantity greater than 10 times the Appendix C quantities. North Carolina Tracking ID: NC 190016 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

ENS 54045 +/-
Where
Moses Cone Hospital Greensboro, North Carolina (NRC Region 1)
License number:	041-0021-1
Organization:	Nc Div Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+35.5 h1.479 days <br />0.211 weeks <br />0.0486 months <br />)
Opened:	Travis Cartoski 15:30 May 3, 2019
NRC Officer:	Jeffrey Whited
Last Updated:	May 3, 2019
54045 - NRC Website
v • d • e

v t e Emergency Notification System
Moses Cone Hospital with Agreement State
WEEKMONTHYEAR2019-05-02T04:00:00 [Table view]
[ENS list for Moses Cone Hospital]

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ENS Notification