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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 55621 | 30 November 2021 07:00:00 | Agreement State | Agreement State - Lost I-125 Seed | The following was received from the Arizona Department of Health Services (the Department) via email: On December 1, 2021, the Department was notified by the licensee of one missing I-125 radioactive seed for breast tumor localization. According to the licensee, one IsoAid Advantage I-125 breast localization seed (approximately 0.4 mCi) was removed by surgery on 11/30/2021 and was verified to be included in the specimen. The specimen with the seed was delivered to pathology on the afternoon of 11/30/21. When a nuclear medicine technologist went to retrieve the seed from pathology, the technologist noticed only a marker and not an actual seed. Nuclear Medicine performed surveys of pathology, pathology staff, the operating room and hallways leading from surgery to pathology. The licensee was unsuccessful in locating the missing I-125 seed. The Department has requested additional information and continues to investigate the event. Arizona Incident Number 21-012 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 |