ENS 57547
ENS Event | |
|---|---|
06:00 Feb 5, 2025 | |
| Title | Lost I-125 Seed |
| Event Description | The following information was provided by the Illinois Emergency Management Agency (the Agency) via phone and email:
The Agency was contacted on 2/13/25, by the University of Chicago to report the inadvertent disposal of a an I-125 brachytherapy seed down the facility's sink drain. The loss is believed to have occurred during sterilization prior to implant on 2/5/25. Five extra sterilized and packaged I-125 seeds were brought to the facility's radiation oncology department in the event they were needed for the procedure. The extra seeds were not needed and the unopened package was taken to the source storage room. It is unclear if surveys of the unused seeds were performed as required. On 2/12/25, the package believed to contain the five I-125 seeds was opened and found to be empty. Radiation safety staff surveyed applicable areas and located four of the five seeds in the sterilization area's sink drain. The fifth seed was not located and is being reported as lost, with the likely disposition of being inadvertently disposed of via the sanitary sewer. The brachytherapy seed has decayed to approximately 0.344 millicuries and would have an exposure rate of just over 2 millirem per hour at six inches. [The original activity of the I-125 brachytherapy seed was 0.405 millicuries.] The loss is reportable to the U.S. NRC within 30 days. Agency inspectors will conduct a reactive inspection to determine root cause and measures taken to prevent a recurrence. This report will be updated as additional information becomes available. Illinois Item Number: IL250006 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 | |
|---|---|
| University Of Chicago Hospital Chicago, Illinois (NRC Region 3) | |
| License number: | IL-01678-02 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+224.55 h9.356 days <br />1.337 weeks <br />0.308 months <br />) | |
| Opened: | Gary Forsee 14:33 Feb 14, 2025 |
| NRC Officer: | Ernest West |
| Last Updated: | Feb 14, 2025 |
| 57547 - NRC Website | |
University Of Chicago Hospital with Agreement State | |
WEEKMONTHYEARENS 575472025-02-05T06:00:0005 February 2025 06:00:00
[Table view]Agreement State Lost I-125 Seed ENS 553102021-06-15T05:00:00015 June 2021 05:00:00 Agreement State Medical Event - Underdose ENS 540192019-04-19T05:00:00019 April 2019 05:00:00 Agreement State Agreement State Report - Lost and Recovered I-125 Source ENS 531272017-12-15T06:00:00015 December 2017 06:00:00 Agreement State Agreement State Report - Underdose ENS 422072005-09-12T06:00:00012 September 2005 06:00:00 Agreement State Illinois Agreement State Report - Medical Misadministration 2025-02-05T06:00:00 | |