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 |
| 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 | |
Cleveland Clinic with Agreement State | |
WEEKMONTHYEARENS 567542023-09-20T04:00:00020 September 2023 04:00:00
[Table view]Agreement State Missing I-125 Seed ENS 493662013-05-09T04:00:0009 May 2013 04:00:00 Agreement State Medical Event Involving Dose to the Wrong Organ 2023-09-20T04:00:00 | |