ENS 56207
ENS Event | |
|---|---|
04:00 Jul 20, 2022 | |
| Title | Lost Licensed Material (Medical Seeds) |
| Event Description | The following information was provided by the New York State Department of Health (the Department) via fax:
On August 16, 2022, the Department was notified of a missing I-125 localization seed (lsoAid I-125, Serial No. 78315 Activity: 0.025 millicurie) at a licensed medical facility in New York. On July 18, 2022, there were two patients, one seed in each of 2 patients was removed. Radiograph of the specimens showed seeds and biopsy clips were present. On July 20, 2022, the Nuclear Medicine technologist was called to retrieve the 2 seeds in a leaded container. Upon further survey, the technologist discovered there was only one seed, and the other was a biopsy clip. The Nuclear Medical Technologist surveyed the pathology lab, including benches, trash and floor but was then informed that the seeds were retrieved from the specimens the day before on July 19, 2022. The laboratory manager, radiology manager and nuclear medicine technologist tracked the path of seeds including the pathology lab, the operating room and hallways. Radioactive trash was also surveyed for radioactivity. The Radiation Safety Office and Medical Physicist were then notified of the missing seed. Corrective actions are in place including: 1. Nuclear Medicine will be notified immediately when a seed is retrieved from a specimen. 2. When retrieving the seed from the specimen, the survey meter must be used to ensure the seed is present. 3. Temporary pathology workers will not work with radioactive seeds. NY Event Report ID: NYDOH-22-06 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 | |
|---|---|
| New York State Dept. Of Health New York (NRC Region 1) | |
| License number: | 0509 |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+2577.43 h107.393 days <br />15.342 weeks <br />3.531 months <br />) | |
| Opened: | Daniel Samson 13:26 Nov 4, 2022 |
| NRC Officer: | Karen Cotton-Gross |
| Last Updated: | Nov 4, 2022 |
| 56207 - NRC Website | |
New York Department of Health with Agreement State | |||
WEEKMONTHYEARENS 562072022-07-20T04:00:00020 July 2022 04:00:00 Agreement State Lost Licensed Material (Medical Seeds) ENS 548942020-09-09T04:00:0009 September 2020 04:00:00 Agreement State | Agreement State Report - Medical Event - Underdose ENS 549022020-08-11T04:00:00011 August 2020 04:00:00 Agreement State | Agreement State Report - Lost I-125 Seed ENS 548362020-06-25T04:00:00025 June 2020 04:00:00 Agreement State Agreement State Reort - Missing I-125 Seed ENS 545822020-01-27T04:00:00027 January 2020 04:00:00 Agreement State Agreement State Report - Missing Iodine-125 Seed ENS 454802009-11-03T05:00:0003 November 2009 05:00:00 Agreement State Agreement State Report Involving Leaking Irradiator Source 2022-07-20T04:00:00 [Table view] | |