ENS 54902
ENS Event | ||
|---|---|---|
04:00 Aug 11, 2020 | ||
| Title | Agreement State Report - Lost I-125 Seed | |
| Event Description | The following information was obtained from the state of New York via facsimile:
On September 9, 2020, the Department [New York State Department of Health] was notified of a missing I-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 251 microCuries) at Roswell Park Cancer Institute in Buffalo, New York. In this incident two seeds were placed into a patient on 8/10/2020 and removed on 8/11/2020. Removal of the seeds from the patient was confirmed by x-ray in the operating suite. The seeds were then sent to the Frozen Section Room for margin check then sent to the Grossing Room in Pathology. After slicing in the Grossing Room, the specimen was x-rayed again and only one seed was visualized. Pathology believed that the seed was in the Frozen Section Room and immediately searched and surveyed both the Frozen Section Room and the Grossing Room, then notified the RSO [radiation safety officer] when the seed was not found. The RSO and an assistant surveyed the OR suite, Frozen Section Room and Grossing Room. Trash from all three locations was surveyed and after three days radioactive waste was surveyed and examined but the seed was still not recovered. In the time between the incident and reporting to the Department, searches and surveys were performed in Surgery, Pathology, Radiation Safety and Environmental Service areas. In addition, trash, regulated medical waste, and radioactive waste were surveyed and inspected. The seed has not been recovered. Ultimate disposition of the source is unknown and it is possible that the source may still be recovered. New York Event Report ID No.: NYDOH-20-04 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 | |
|---|---|
| New York State Dept. Of Health Buffalo, New York (NRC Region 1) | |
| License number: | 2923 |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+877.27 h36.553 days <br />5.222 weeks <br />1.202 months <br />) | |
| Opened: | Daniel J. Samson 17:16 Sep 16, 2020 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Sep 16, 2020 |
| 54902 - NRC Website | |
New York Department of Health with Agreement State | |||
WEEKMONTHYEARENS 562072022-07-20T04:00:00020 July 2022 04:00:00 Agreement State Lost Licensed Material (Medical Seeds) ENS 548942020-09-09T04:00:0009 September 2020 04:00:00 Agreement State | Agreement State Report - Medical Event - Underdose ENS 549022020-08-11T04:00:00011 August 2020 04:00:00 Agreement State | Agreement State Report - Lost I-125 Seed ENS 548362020-06-25T04:00:00025 June 2020 04:00:00 Agreement State Agreement State Reort - Missing I-125 Seed ENS 545822020-01-27T04:00:00027 January 2020 04:00:00 Agreement State Agreement State Report - Missing Iodine-125 Seed ENS 454802009-11-03T05:00:0003 November 2009 05:00:00 Agreement State Agreement State Report Involving Leaking Irradiator Source 2022-07-20T04:00:00 [Table view] | |