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Start date | Reporting criterion | Title | Event description | System | LER | |
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ENS 42281 | 20 January 2006 20:00:00 | 10 CFR 20.2201(a)(1)(i) | Lost Iodine Seeds | After an implantation procedure using Iodine 125 seeds was performed at 1500 at Mercy Hospital of Scranton, PA the staff became aware that there were potentially 2 seeds missing. The total activity of the 2 seeds is estimated to be 1.26 millicuries. The hospital ordered 88 seeds for this operation. 68 seeds were implanted in the patient. The number of implanted seeds was verified using an x-ray. After the operation the hospital counted 18 remaining seeds for return shipment to the seed provider thus, 2 seeds were unaccounted for. The hospital performed surveys of the operating room and was unable to locate any other seeds. At the time of the report the operating room was quarantined for further investigation. The hospital contacted the health services company that sterilized the seeds to determine if fewer seeds were provided but Anazao Heath was unable to provide an exact count of the seeds. On Monday 1/23/06 the Radiation Safety Officer plans to contact the seed provider, Amersham Health to determine an exact count of seeds shipped. 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. |