ENS 56677
ENS Event | |
|---|---|
19:28 Aug 10, 2023 | |
| Title | NON-AGREEMENT State Report - Loss of Radioactive Seeds |
| Event Description | The following information was provided by the Defense Health Agency via email:
The discovery of the loss of 10 radioactive (0.300 mCi each, I-125; total of 3 mCi) seeds used for localization of non-palpable breast lesions occurred on August 10, 2023, when mammography reported a Pyxis inventory discrepancy to health physics (HP). The seeds were likely lost between August 3, 2023, and August 10, 2023. The Brooke Army Medical Center (BAMC) breast imaging (mammography) section is missing 10 radioactive seeds from the mammography Pyxis. The loss of 10 radioactive (0.300 mCi each, I-125; total of 3 mCi) seeds used for localization of non-palpable breast lesions occurred on August 10, 2023 (batch number 56406). This batch of 10 seeds was received from the nuclear medicine pharmacist and logged into the BAMC health physics radiological science lab (RSL) seed tracking log on May 11, 2023. A second batch of 10 seeds (batch number 56668) was retrieved by mammography personnel from nuclear medicine and logged in to the BAMC health physics RSL seed tracking log on June 15, 2023. As of June 15, 2023, the mammography Pyxis had 20 radioactive seeds present. The first procedure, using radioactive seeds from either batch, was August 3, 2023. When the mammography nurse went to log the seed used on August 3, 2023, into the tracking log (seed number 56668-1), she noticed that no seeds from the number 56406 batch had been used. This is atypical because they are always used in sequential order. At this time, she also noticed that the number 56406 batch (received on May 11, 2023) was physically placed behind the number 56668 batch (received June 15, 2023) in the designated Pyxis bin. This is also atypical, as seeds are used in sequential order from oldest batch to newest batch. Following the August 3, 2023, procedure, the seed count, post procedure, was 19 radioactive seeds (9 in batch number 56668 and 10 in batch number 56406). The next radioactive seed was placed on August 10, 2023 (seed number 56668-2) giving a radioactive seed count of 8 in batch number 56668. At this time, it was discovered that the entire batch of number 56406, seeds 1-10, was missing from the Pyxis. Health physics confirmed today, August 11, 2023, that missing batch number 56406, seeds 1-10, is not currently expired, and should not have been removed from the Pyxis. The current seed receipt and exchange process is once the seeds are received in mammography from nuclear medicine they are placed in the Pyxis. A note is left in the Pyxis for the logistics technician to only update the count in the Pyxis. The established procedure is that the logistics personnel are not to remove any seeds from the Pyxis whether they are expired or not, and to only to update the count. When seeds expire, they are retrieved by health physics after notification by mammography staff. The process for removing expired seeds in the Pyxis is to bundle them and label them as expired. Health physics is contacted for pick up. Seed packaging information is copied and signed by health physics. Health Physics takes a copy, and a copy of the transfer is retained by mammography team. BAMC has transitioned 90 percent of radioactive seed utilization to magseeds. On Friday morning, August 11, 2023, HP met with logistics and mammography personnel. The seeds were searched for by multiple representatives from HP, mammography and logistics personnel. The Pyxis system in mammography was thoroughly searched along with logistics areas that expired products are routed through to include sharps containers and mammography work areas. Due to the seeds being shielded, the RAM waste alarm log was not reviewed. If logistics accidentally removed the seeds from the Pyxis for disposal, the seeds would show up on a transfer receipt before being packaged for waste disposal to the landfill. At 1500 on August 11, 2023, BAMC HP declared the seeds lost. HP requested that all Pyxis systems on the 1st floor be searched for the seeds in case they were inadvertently placed there during inventories. There was no mission impact to healthcare. This is an NRC reportable event. The corrective actions taken were to immediately remove the remaining 8 seeds from the Pyxis and currently store them in the radioactive material (RAM) waste shed until one is required for a procedure. Mammography was informed of the new procedure in which they will contact HP the day before a scheduled procedure to coordinate the delivery of a seed from HP. This action ensures that only HP has possession of seeds until one is needed. All RSL seeds will be in possession of HP and locked in the storage shed until mammography needs one for a procedure. The chain of custody starts and ends with HP, thus preventing logistics from mistakenly removing them from the Pyxis system." 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 | |
|---|---|
| Defense Health Agency San Antonio, Texas (NRC Region 1) | |
| License number: | 4535423-01 |
| Organization: | Defense Health Agency |
| Reporting | |
| 10 CFR 20.2201(a)(1)(i) | |
| Time - Person (Reporting Time:+25.08 h1.045 days <br />0.149 weeks <br />0.0344 months <br />) | |
| Opened: | Ricardo Reyes 20:33 Aug 11, 2023 |
| NRC Officer: | Karen Cotton-Gross |
| Last Updated: | Aug 11, 2023 |
| 56677 - NRC Website | |
Defense Health Agency with 10 CFR 20.2201(a)(1)(i) | |
WEEKMONTHYEARENS 566772023-08-10T19:28:00010 August 2023 19:28:00
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