ENS 55140
ENS Event | |
|---|---|
05:00 Mar 11, 2021 | |
| Title | Lost I-125 Brachytherapy Seed |
| Event Description | The following was received from the state of New York:
A sealed source (BEST Model 2300) containing iodine -125 with an activity (actual) of 1.79 megabecquerel (48.28 microCurie) on the date of clinical use was implanted into the patient as part of a seed localization procedure on January 8, 2021 and verified by x-ray image as to its location. The patient reported for surgery on January 11, 2021, but the seed could not be located by intra operative radiation probe, portable radiation instrumentation or x-ray. After surveys and discussions with staff and the patient, it is presumed that the seed washed down the drain or removed in household trash while at the patient's home. Two scenarios are used to estimate a dose to a member of the public from the lost seed. 1) Seed washed down the drain evening prior to reporting for surgery. The estimated dose to the public is less than1 millirem. 2) Seed displaced in home the day prior to reporting for surgery. The estimated deep dose equivalent to an individual from the sealed source based on the activity of the seed before the date of surgery until the date of survey in the residence is approximately 3 mrem. The seed final disposition is presumed removed with household trash. Surveys were conducted with the appropriate radiation instrumentation on the patient, in the procedure room, in the implant facility, and at the patient's home. Procedures or measures that have been or will be, adopted to ensure against a recurrence of the loss or theft of licensed or registered sources of radiation. Patient education material is updated. Patients instructed to not remove SteriStrip following radioactive seed localization implantation. New York Event Report ID: NYDOH-21-01 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 City Bureau Of Rad Health New York (NRC Region 1) | |
| Organization: | New York City Bureau Of Rad Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+103.57 h4.315 days <br />0.616 weeks <br />0.142 months <br />) | |
| Opened: | Daniel Samson 11:34 Mar 15, 2021 |
| NRC Officer: | Lloyd Desotell |
| Last Updated: | Mar 15, 2021 |
| 55140 - NRC Website | |
New York City Bureau Of Rad Health with Agreement State | |
WEEKMONTHYEARENS 551402021-03-11T05:00:00011 March 2021 05:00:00
[Table view]Agreement State Lost I-125 Brachytherapy Seed 2021-03-11T05:00:00 | |