ENS Event | |
|---|---|
06:00 Aug 19, 2021 | |
| Title | Lost Brachytherapy Seed |
| Event Description | The following information was received from the state of Minnesota via email:
It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO. Fairview Southdale Hospital (FSH) reported a missing 8.36 MBq (226 microCi) I-125 localization seed (IsoAid model IAI-125A). The seed was discovered missing on 8/19/2021. Two I-125 seeds were placed in a patient for localization of non-palpable lesions. Both seeds were removed in the operating room, which was confirmed by imaging. The tissue was sealed in a container in the operating room and taken to Pathology. During processing of the tissue, Pathology could only locate one of the seeds. FSH surveyed the operating room and Pathology. The seed was not located. The operating room had been cleaned prior to the survey. It is not known if the seed went missing in the operating room or Pathology. FSH planned to modify their procedure to place the specimen in a Zip-Lock bag before being imaged in the operating room and kept in the bag when transported to Pathology. Also, Pathology will analyze the specimen in a timely fashion so if a seed does go missing, it will have less time to be moved around. Minnesota event number: 210006 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 | |
|---|---|
| Fairview Southdale Hospital Edina, Minnesota (NRC Region 3) | |
| License number: | 1039 |
| Organization: | Minnesota Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+2863.28 h119.303 days <br />17.043 weeks <br />3.922 months <br />) | |
| Opened: | Sherrie Flaherty 14:17 Dec 16, 2021 |
| NRC Officer: | Mike Stafford |
| Last Updated: | Dec 16, 2021 |
| 55654 - NRC Website | |
Fairview Southdale Hospital with Agreement State | |
WEEKMONTHYEARENS 556542021-08-19T06:00:00019 August 2021 06:00:00
[Table view]Agreement State Lost Brachytherapy Seed ENS 556562019-12-05T06:00:0005 December 2019 06:00:00 Agreement State Lost Brachytherapy Seed 2021-08-19T06:00:00 | |