ENS Event | |
|---|---|
15:00 Aug 11, 2025 | |
| Title | Lost I-125 Seed |
| Event Description | The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:
On August 11, 2025, three radioactive iodine-125 sealed sources (seeds) were removed from a patient receiving a radioactive seed localization procedure. The licensee expected to remove four I-125 seeds, which were placed in the patient on August 8, 2025, but only located three of the seeds. The missing seed was not located after extensive surveys of the patient, staff, and all areas where the seed may have been misplaced. The seed has not been located at this time. This is a 30-day reporting requirement per [Code of Massachusetts Regulations] 105 CMR 120.281(A)(2), missing licensed radioactive materials in aggregate quantity equal to or greater than 10 times quantity specified in 105 CMR 120.297, Appendix C. The Agency considers this event to be open. Manufacturer: IsoAid, LLC Model: IAI-125A Source: 0.181 mCi I-125 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 | |
|---|---|
| Baystate Health Springfield, Massachusetts (NRC Region 1) | |
| License number: | 60-0095 |
| Organization: | Ma Radiation Control Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+694.6 h28.942 days <br />4.135 weeks <br />0.951 months <br />) | |
| Opened: | Bob Locke 13:36 Sep 9, 2025 |
| NRC Officer: | Josue Ramirez |
| Last Updated: | Sep 9, 2025 |
| 57911 - NRC Website | |
Baystate Health with Agreement State | |
WEEKMONTHYEARENS 579112025-08-11T15:00:00011 August 2025 15:00:00
[Table view]Agreement State Lost I-125 Seed ENS 510092015-04-22T04:00:00022 April 2015 04:00:00 Agreement State Agreement State Report - Bulk Dose Administered to Patient 2025-08-11T15:00:00 | |