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 Start dateReporting criterionTitleEvent descriptionSystemLER
ENS 5679914 September 2023 04:00:00Agreement StateLost Seed SourceThe following is a summary of information provided by the Georgia Radioactive Materials Program via email: On September 14, 2023, the licensee determined that an iodine-125 seed used for non-palpable lesion localization had been lost. Two seeds had been previously implanted in a patient. On September 12, 2023, a specimen containing both seeds was removed from the patient. When transported to pathology lab, only one seed was located in the specimen. It was confirmed through survey and imaging that the seed was no longer in the patient, and it is suspected that the seed was lost in the operating room. At the time of the loss, the seed had an activity between 0.218 and 0.221 millicuries. After conducting a search of the operating room, the surgical equipment, and the pathology lab, the radiation safety officer declared the source lost on September 14, 2023. Georgia NMED Incident Number: 71 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