ENS 54578

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v t e ENS Event
06:00 Mar 9, 2020
Title	Agreement State Report - Lost Iodine-125 Seed
Event Description	The following information was received from the state of Utah via email: Late in the evening on March 9, 2020, an individual in the pathology lab was examining an excised tissue sample that contained one 286 microCurie Iodine-125 seed used in a radioactive seed localization procedure. During the examination, the seed fell out of the tissue sample and went down the sink drain. The individual blocked off the drain, and the licensee waited until the morning of the 10th to remove the sink's p-trap to look for the seed. The licensee was unable to locate the seed, and assumes that the seed is lost. The Division [Utah Division of Radiation Control] will be performing an on-site investigation soon. Utah Report ID number: UT200002 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 54578 +/-
Where
Utah Division Of Radiation Control Salt Lake, Utah (NRC Region 4)
License number:	UT 1800253
Organization:	Utah Division Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+34.22 h1.426 days <br />0.204 weeks <br />0.0469 months <br />)
Opened:	Philip Griffin 16:13 Mar 10, 2020
NRC Officer:	Silas Kennedy
Last Updated:	Mar 10, 2020
54578 - NRC Website
v • d • e

v t e Emergency Notification System
Utah Division of Radiation Control with Agreement State
WEEKMONTHYEAR		Agreement State Report - Incorrect Radionuclide Administered to a Patient 2020-09-16T19:00:00 [Table view]
[ENS list for Utah Division of Radiation Control]

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ENS Notification