ENS 55262
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ENS Event | |
|---|---|
00:00 May 13, 2021 | |
| Title | Missing Iodine-125 Brachytherapy Seeds |
| Event Description | A brachytherapy treatment was performed at the hospital on 13 May 2021. From a total of 111 Iodine -125 seeds, 88 were implanted into the patient's prostate as planned. The oncology medical physicist mistakenly thought that she had placed the remaining, unused 23 in two lead containers, but did not perform a physical inventory to confirm it. She did not realized that 4 unused seeds were left in a shielded box. Each seed had approximately 0.26 mCi in each. After the procedure, Radiation Safety surveyed the treatment room. All radiation levels were background. The medical physicist returned the unused seeds to Radiation Safety indicating that 23 seeds were in two small lead pigs. The box containing the 4 seeds was put in the medical waste bag and were apparently processed as medical waste. On 14 May 2021, Radiation Safety initiated preparing the unused seeds for shipment to the vendor that provided them. At that point, Radiation Safety realized that only 19 were in the lead containers and 4 were not returned. At that point, Radiation Safety contacted Radiation Oncology. They were not able to locate them at their department. A team consisting of Radiation Safety and Radiation Oncology staff searched for them, unsuccessfully, in the [Operating Room]. The team then searched in the medical waste dumpster bins at the hospital. This search was also unsuccessful locating the missing seeds. It was determined that a dumpster container that likely had the missing seeds was picked up early in the day. The waste management company was contacted, but the company was not able to provide information about what truck or container was involved and its location. The hospital is currently waiting for more information from the waste management company.
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 | |
|---|---|
| Defense Health Agency San Diego, California (NRC Region 1) | |
| License number: | 45-35423-01 |
| Organization: | Defense Health Agency |
| Reporting | |
| 10 CFR 20.2201(a)(1)(i) | |
| Time - Person (Reporting Time:+116.25 h4.844 days <br />0.692 weeks <br />0.159 months <br />) | |
| Opened: | Col. Ricardo Reyes 20:15 May 17, 2021 |
| NRC Officer: | Brian Lin |
| Last Updated: | May 17, 2021 |
| 55262 - NRC Website | |
Defense Health Agency with 10 CFR 20.2201(a)(1)(i) | |
WEEKMONTHYEARENS 566772023-08-10T19:28:00010 August 2023 19:28:00
[Table view]10 CFR 20.2201(a)(1)(i) NON-AGREEMENT State Report - Loss of Radioactive Seeds ENS 552622021-05-13T00:00:00013 May 2021 00:00:00 10 CFR 20.2201(a)(1)(i) Missing Iodine-125 Brachytherapy Seeds 2023-08-10T19:28:00 | |
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