ENS 55410
ENS Event | |
|---|---|
07:00 Jul 26, 2021 | |
| Title | Lost IODINE-125 Seeds |
| Event Description | The following is a summary of a report received from the state of Washington via email:
On Monday, 7/26/2021, nuclear cardiology personnel identified and reported a loss of Radioactive Seed Localization (RSL) seeds. Background: RSL seeds are obtained by the Polyclinic as individually loaded implant needles containing one seed, in sterile, one needle use packs. Nuclear cardiology personnel receive the seed shipments, conduct the required surveys and maintain a seed inventory. Needle packs are distributed to mammography personnel on days of RSL seed implant. On Wednesday, 7/21/2021, the seed was obtained by mammography personnel. The intent was not for RSL implant, but rather to utilize the needle for qualification of new Hologic mammography equipment. The needle pack was provided to the Hologic applications technologist for the qualification. Mammography personnel indicated that the Hologic applications technologist unexpectedly opened the needle pack and ejected the seed within the plastic sterile pack as she needed the needle not the RSL seed. Mammography personnel took the pack, and seed, and stored the pack. At the end of the day, mammography personnel indicated they taped the pack closed and returned the pack to the nuclear cardiology hot lab. On Thursday, 7/22/2021, mammography personnel again took the needle pack from the hot lab, and utilized the needle for equipment qualification, indicating that the pack, and seed, was returned again to the nuclear cardiology hot lab at the end of the day. Mammography personnel indicate that the seed was visible in the pack at the end of the day. On Monday, 7/26/2021, nuclear cardiology personnel indicated that the subject pack was visually inspected and no seed was identified. Nuclear cardiology personnel indicated the needle pack was surveyed with an exposure rate calibrated Ludlum 14C w/ 44-9 GM pancake and no evidence of the seed was identified. Nuclear cardiology personnel also indicated the lead foil shielded box was similarly visually inspected and surveyed and no evidence of the seed was identified. On Tuesday, 7/27/2021, nuclear cardiology personnel surveyed the Nuclear Cardiology hot lab and other areas. Nuclear cardiology personnel indicated that no evidence of the seed presence was identified. Washington State Incident Number: WA-21-019 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 | |
|---|---|
| Polyclinic Seattle, Washington (NRC Region 4) | |
| License number: | WN-M0218 |
| Organization: | Wa Office Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+536.55 h22.356 days <br />3.194 weeks <br />0.735 months <br />) | |
| Opened: | Tristan Hay 15:33 Aug 17, 2021 |
| NRC Officer: | Kerby Scales |
| Last Updated: | Aug 17, 2021 |
| 55410 - NRC Website | |
Polyclinic with Agreement State | |
WEEKMONTHYEARENS 554102021-07-26T07:00:00026 July 2021 07:00:00
[Table view]Agreement State Lost IODINE-125 Seeds 2021-07-26T07:00:00 | |