ENS 57503
ENS Event | |
|---|---|
05:00 Jan 10, 2025 | |
| Title | Damaged I-125 Seed |
| Event Description | The following is a summary of information provided by the licensee via phone and email:
On January 10, 2025, two seeds were removed from a patient and placed in a safe in pathology. On January 14, 2025, a nuclear medicine technologist, retrieved the seeds from the safe for check-in with nuclear medicine. When checking in the used seeds the technologist noticed one of the seeds was shorter in length than the other. A seed evaluation was performed and comparisons revealed that seeds were different in size and that the shorter seed appeared to be hollow. The pathology assistant ceased working and pulled excisions from the patient. Access to the workspace area was restricted. After surveying all tissue samples, only one tissue sample was determined to be radioactive. The radioactive tissue was then immediately placed in a locked box in pathology. The cutting workspace area was surveyed and determined not to be contaminated. A medical health physicist consultant from Ohio Medical Physics Consulting (OMPC) was contacted for further direction. A radiation safety officer (RSO) was called but was not in the office at the time. Therefore, a medical physicist took the call. The entire work area and the personnel in pathology were re-surveyed. After the second set of surveys was completed, all surfaces, floors, and previous instruments used in cutting the samples were all determined to be background. All trash and biohazard material in the pathology lab was surveyed. All surveyed material read background. The compactor and biohazard storage room were surveyed and resulted in background readings. Surgery and the cold room, where the samples were stored prior to coming to pathology, were also surveyed. The room and storage area measured background. A radiologist was consulted regarding the imaging that was taken at the time of surgery. He stated specimen radiograph demonstrates the coil clip and the I-125 seed as well as the circular clip. The I-125 seed associated with the axillary clip was not imaged. The imaging director and RSO were then notified of the events. The RSO then requested to have the tissue and any items the tissue had come in contact within pathology surveyed. The specimen was determined to be radioactive along with blocks and slides the sample was placed on. A total of 9 blocks and 4 slides were determined to be contaminated. All items were placed in a lockbox. After which another area survey was completed including the pathologist's microscope, tissue processor, embedding center, microtome, and stainer. All equipment measured background. Wipe tests were also completed and measured background. The seed and the contaminated blocks and slides will be stored in the nuclear medicine hot lab until it is deemed safe to dispose of properly. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The I-125 seed contained an estimated activity of 269 microcuries. |
| Where | |
|---|---|
| Goshen General Hospital Goshen, Indiana (NRC Region 3) | |
| License number: | 13-18845-01 |
| Organization: | Goshen General Hospital |
| Reporting | |
| 10 CFR 30.50(b)(2), Licensed Material Protection Equipment Failure | |
| Time - Person (Reporting Time:+297.05 h12.377 days <br />1.768 weeks <br />0.407 months <br />) | |
| Opened: | Samantha Korda 14:03 Jan 22, 2025 |
| NRC Officer: | Josue Ramirez |
| Last Updated: | Jan 22, 2025 |
| 57503 - NRC Website | |
Goshen General Hospital with 10 CFR 30.50(b)(2) | |
WEEKMONTHYEARENS 575032025-01-10T05:00:00010 January 2025 05:00:00
[Table view]10 CFR 30.50(b)(2) Damaged I-125 Seed ENS 575772022-05-20T05:00:00020 May 2022 05:00:00 10 CFR 30.50(b)(2) Damaged I-125 Seed 2025-01-10T05:00:00 | |