ENS 55378
ENS Event | |
|---|---|
04:00 Jun 30, 2021 | |
| Title | Lost I-125 Brachytherapy Seed |
| Event Description | The following was received via email from the North Carolina Radiation Protection Section (NC RPS) via email:
On 07/06/2021 at 1554 EDT [the licensee] Chief Diagnostic Medical Physicist emailed NC RPS about a lost Iodine-125 seed. Seeds are used for localization of non-palpable breast nodules. The event occurred on 06/30/2021 but was not reported to [the Chief Diagnostic Medical Physicist] until 07/06/2021. On 07/07/2021 North Carolina Inspections Supervisor forwarded the email to an Inspector for review. The seed was assayed on 06/09/2021 with an activity of 0.15 mCi. The event originated at Atrium Health Union, 600 Hospital Drive, Monroe, NC 28112 under license number 090-0739-1. The seed was identified by imaging at the Monroe Breast Center prior to shipment. Surveys of the transport container were also performed before it left the facility confirming the seed was present. Image was included with follow up email. Atrium Health Union nuclear medical staff used a Ludlum Mo. 14-C with GM pancake probe, serial number 73404, calibration due 07/28/2021. Survey of package exterior showed a reading of 0.05 mR/hr and less than 0.02 mR/hr at one meter. The package left the facility at 1347 EDT on 06/30/2021. A courier service is used to transport specimens. Charlotte-Mecklenburg Hospital Authority's Carolinas Medical Center (CMC) pathology lab received the package at 1525 EDT on 06/30/2021. CMC pathology lab staff failed to perform package survey at time of receipt. The specimen was removed from the transport case and radiographed using a Faxitron cabinet x-ray unit on 06/30/2021. At this point, pathology staff found that the seed was not present in the specimen tissue. Image was included with initial notification email. At this point, pathology staff did not follow established procedures to notify CMC Radiation Safety staff. On 07/06/2021 [the CMC] Radiation Safety Officer (RSO) was notified of the incident. Radiation Safety staff immediately went to the CMC pathology lab and surveyed the lab using a Ludlum Mo. 2241 with a NaI probe, serial number 217339. Surveying began at 0830 EDT on 07/06/2021. The transport container, all work areas, all biological waste containers, floor areas, counters, and all areas where the seed could be located were surveyed. All readings were at background radiation levels (<0.02 mR/hr) and seed was not located. Seed Information: Manufacturer: Best Medical Lot#: 52188A-6 Radiation Type: low E gamma emitter Activity: 0.15 mCi, assayed on 06/09/2021 Licensee identified multiple failures which lead to the incident, including: 1. Failure of pathology lab staff to carefully handle specimen. 2. Failure to notify RSO at initial finding of incident. 3. Failure of pathology lab to follow established procedures. 4. Receiving notification at such a later date greatly diminishes likelihood of finding lost seed. Licensee proposed several corrective actions to prevent reoccurrence, including: 1. All pathology staff on radiation program will receive refresher training. 2. CMC pathology will have more accountability regarding the handling of radioactive material. 3. All specimens containing radioactive material received from outside facilities must be received at CMC pathology lab prior to 1600 EDT. 4. Extra stickers and labels will be utilized to clearly identify specimens containing radioactive material. 5. CMC pathology lab will handle specimens with extreme caution due to small size of seeds. North Carolina Incident Number: NC210012 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 | |
|---|---|
| Charlotte-Mecklenburg Hospital Authority Charlotte, North Carolina (NRC Region 1) | |
| License number: | 060-0014-3 |
| Organization: | North Carolina Div Of Rad Protectio |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+563.87 h23.495 days <br />3.356 weeks <br />0.772 months <br />) | |
| Opened: | Travis Cartoski 15:52 Jul 23, 2021 |
| NRC Officer: | Lloyd Desotell |
| Last Updated: | Jul 23, 2021 |
| 55378 - NRC Website | |
Charlotte-Mecklenburg Hospital Authority with Agreement State | |
WEEKMONTHYEARENS 553782021-06-30T04:00:00030 June 2021 04:00:00
[Table view]Agreement State Lost I-125 Brachytherapy Seed ENS 448232009-01-27T05:00:00027 January 2009 05:00:00 Agreement State Agreement State Report - Medical Event 2021-06-30T04:00:00 | |