ENS 54564
ENS Event | |
|---|---|
05:00 Aug 9, 2016 | |
| Title | Agreement State Report - Lost I-125 Source |
| Event Description | The following was received from the State of Georgia via e-mail:
The Georgia Radiation Materials Program received a call from the [Radiation Safety Officer] RSO from Grady Memorial Hospital on August 12, 2016, stating the [200 microCurie] I-125 seed used for localization of non-palpable lesions was lost. The doctor performing the procedure stated the seed went into the tube of the suction tank. A survey of the suction tank, hallways and operating room did not uncover the lost source. The tissue, removed from the patient, which was transferred to pathology, also did not contain the source. The surveys of the hallway and operating room were performed after the hospital was notified. The RSO recommends bringing the patient back in the hospital to be surveyed to verify if the source was ever removed from the patient. At the time of the call, the RSO has been unable to speak to the doctor. The doctor is a surgeon and not an authorized user. The RSO stated the tube to the suction tank cannot be found and it may have made its way into the biohazard container. The RSO will follow-up with the biohazard department to see if the tube can be traced down so the tube can be surveyed to determine if the source became lodged within it. The RSO is also trying to follow-up with the doctor for more information. NMED Report ID: 160362 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 | |
|---|---|
| Georgia Radioactive Material Pgm Atlanta, Georgia (NRC Region 1) | |
| License number: | GA 258-2 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+31301.13 h1,304.214 days <br />186.316 weeks <br />42.876 months <br />) | |
| Opened: | John Hays 11:08 Mar 5, 2020 |
| NRC Officer: | Jeffrey Whited |
| Last Updated: | Mar 5, 2020 |
| 54564 - NRC Website | |
Georgia Radioactive Material Program with Agreement State | ||||
WEEKMONTHYEARENS 560652022-08-23T16:00:00023 August 2022 16:00:00 Agreement State Lost Radioactive Portable Gauge ENS 548822020-09-02T04:00:0002 September 2020 04:00:00 Agreement State | Agreement State Report - Medical Event - Underdose ENS 548792020-08-27T04:00:00027 August 2020 04:00:00 Agreement State | Agreement State Report - Loss of Medical Seed After Removal from Patient ENS 548172020-07-21T04:00:00021 July 2020 04:00:00 Agreement State | ENS 546942020-05-04T04:00:0004 May 2020 04:00:00 Agreement State Agreement State Report - Patient Underdose ENS 546622020-03-31T04:00:00031 March 2020 04:00:00 Agreement State Agreement State Report - Loss of Iodine-125 Seed ENS 541102019-06-11T04:00:00011 June 2019 04:00:00 Agreement State Agreement State Report - Patient Under Dosage Due to Air Being Trapped in the Delivery Line ENS 545492019-05-02T05:00:0002 May 2019 05:00:00 Agreement State Agreement State Report - Broken Density Gauge Shutter ENS 539962019-04-03T04:00:0003 April 2019 04:00:00 Agreement State Agreement State Report - Underdose Administration of Y-90 Theraspheres ENS 545502019-01-18T05:00:00018 January 2019 05:00:00 Agreement State Agreement State Report - Improper Disposal of I-125 Seed ENS 545412018-12-18T05:00:00018 December 2018 05:00:00 Agreement State Agreement State Report - Leaking Promethium-147 Source ENS 545652018-06-29T05:00:00029 June 2018 05:00:00 Agreement State Agreement State Report - Lost Iodine-125 Seed ENS 545372018-04-03T05:00:0003 April 2018 05:00:00 Agreement State Agreement State Report - Stuck Open Shutter ENS 545632017-11-06T05:00:0006 November 2017 05:00:00 Agreement State Agreement State Report - Leaking Cesium-137 Source ENS 546442017-06-09T04:00:0009 June 2017 04:00:00 Agreement State Agreement State Report - Stuck Shutter ENS 545642016-08-09T05:00:0009 August 2016 05:00:00 Agreement State Agreement State Report - Lost I-125 Source 2022-08-23T16:00:00 [Table view] | |