ENS Event | |
|---|---|
05:00 Dec 14, 2021 | |
| Title | Lost Brachytherapy Seed |
| Event Description | The following was received from the Tennessee Division of Radiological Health via email:
During the removal of I-125 seeds from a patient, only 22 of 23 seeds were recovered. No survey readings above background were discovered in the operating room. It was concluded that the seed was not present in the patient upon operating room entry. Exam rooms visited by the patient were checked and showed no readings above background levels. The seed is thought to have been lost during implant with surgical drape on 12/7/21. The seed information is as follows: Manufacturer: BEST Model: 2301 Isotope: I-125 Activity: 1.6 mCi Corrective actions will be updated with a report within 30 days. State Event Report ID Number: TN-21-117 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 | |
|---|---|
| Methodist Le Bonheur Healthcare Memphis, Tennessee (NRC Region 1) | |
| License number: | R-79027-H26 |
| Organization: | Tennessee Div Of Rad Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+34.8 h1.45 days <br />0.207 weeks <br />0.0477 months <br />) | |
| Opened: | Andrew Holcomb 15:48 Dec 15, 2021 |
| NRC Officer: | Mike Stafford |
| Last Updated: | Dec 15, 2021 |
| 55650 - NRC Website | |
Methodist Le Bonheur Healthcare with Agreement State | |
WEEKMONTHYEARENS 556502021-12-14T05:00:00014 December 2021 05:00:00
[Table view]Agreement State Lost Brachytherapy Seed 2021-12-14T05:00:00 | |