The following information was provided by the
New York Department of Health via email:
A patient at Sisters of Charity Hospital in Buffalo, RAM license 2911, was implanted with a Best Medical International model 2301, serial no. 56305C, I-125 localization seed (108.76 microcurie) on 6/23/23 for a surgical removal scheduled on 6/26/23. The seed was in the breast specimen when it arrived in pathology on 6/26/23 (Activity was 105.08 microcurie) and was supposedly removed, bagged, and stored in the proper storage area. Personnel from nuclear medicine retrieved the seeds from the pathology storage unit on 7/3/23 and filled out the log sheet and the chain of custody paperwork. While bringing the seeds to the nuclear medicine decay closet, a nuclear medical technician (NMT) noticed that one of the bags with seeds in it (they retrieved 4 seeds that day from pathology) had a seed that seemed thicker than the others. Upon further investigation, it was noted that there was a clip and not an I-125 seed in the one bag. NMT staff Immediately went and monitored all areas in pathology (floor, work areas, sharp containers, garbage of the remaining specimen and the patient slides). No activity was noted. Staff contacted the boiler house, and no radioactive waste has been discovered leaving the premises. The licensee believes that the seed possibly went down the drain in the pathology lab. As a precaution, the licensee plans to set up a dedicated area to survey the biohazard bag with the seed in it and the sink drain will be covered during dissection. This seed is considered lost with no reasonable probability of recapture.
New York State Event Report Number: NY-23-06
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