ENS 54565
ENS Event | |
|---|---|
05:00 Jun 29, 2018 | |
| Title | Agreement State Report - Lost Iodine-125 Seed |
| Event Description | The following information was received from the State of Georgia via email:
On June 29, 2018, it was brought to the [Piedmont Fayette Hospital Radiation Safety Officer's] RSO's attention that a radioactive seed containing 62 microCuries of Iodine-125 was unaccounted for and could not be located. The seed was manufactured by Best Medical International, Inc., Model 2301. The physical form is a double wall titanium tube containing a tungsten x-ray marker that is coated with I-125. The source serial/lot number is 45876A-26. The source was calibrated at 100 microCuries on 5/11/2018. On the morning of the seed implantation procedure, 6/27/2018, the source measured at 62 microCuries in the dose calibrator in the hot lab. The seed had been used for localization of a breast lesion. Tissue was extracted from the patient and the specimen was reported to have contained the seed at the time of specimen radiography. Following this radiography procedure, the seed appears to have been lost. All efforts were made by staff on-site to locate and search for the seed in all possible locations, with no success. The patient was brought back in for radiology procedures to ensure that the seed was not still contained in the patient. Results of x-rays showed that the seed was not present in the patient. According to the RSO, it is likely that the seed was disposed of along with the trash collected after the procedure, or possibly washed down the floor drain in the specimen radiography room. According to the RSO, this is a best guess as to the fate of the seed. No individual members of the public or staff were likely to have been exposed to significant doses of radiation, based on the available information submitted to EPD [Georgia Environmental Protection Division]. 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 Fayetteville, Georgia (NRC Region 1) | |
| License number: | GA 1340-1 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+14765.68 h615.237 days <br />87.891 weeks <br />20.226 months <br />) | |
| Opened: | John Hays 11:41 Mar 5, 2020 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Mar 5, 2020 |
| 54565 - 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] | |