ENS 56754

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v t e ENS Event
04:00 Sep 20, 2023
Title	Missing I-125 Seed
Event Description	The following was reported by the Florida Bureau of Radiation Control (BRC) via email: At 1537 EDT on 9/22/23, BRC received a call from Cleveland Clinic stating an I-125 source was lost after removal from a patient. The patient was suspected to have breast cancer, and two I-125 sources were implanted in the breast tissue. The patient returned home 9/18/23 with the implanted seeds, and returned to the clinic 9/20/23 to receive a Tc-99m injection prior to tissue removal. The licensee states they confirmed both seeds were no longer in the patient after surgery, however, when the samples were taken by pathology, only one seed was located in the removed tissue. Cleveland Clinic has completed surveys of the operating room and pathology. Florida incident number: FL23-149 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

ENS 56754 +/-
Where
Cleveland Clinic Weston, Florida (NRC Region 1)
License number:	4818-2
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+60.27 h2.511 days <br />0.359 weeks <br />0.0826 months <br />)
Opened:	Monroe Cooper 16:16 Sep 22, 2023
NRC Officer:	Lawrence Criscione
Last Updated:	Sep 22, 2023
56754 - NRC Website
v • d • e

v t e Emergency Notification System
Cleveland Clinic with Agreement State
WEEKMONTHYEAR2023-09-20T04:00:00 [Table view]
[ENS list for Cleveland Clinic]

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