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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 49760 | 22 November 2013 05:00:00 | Agreement State | Pennsylvania Agreement State Report - Lost Then Found Brachytherapy Seeds | The following information was obtained from the Commonwealth of Pennsylvania via facsimile: Notifications: On November 22, 2013, the DEP (Pennsylvania Department of Environmental Protection) Southwest Regional Office was notified that some palladium-103 (Pd-103) brachytherapy seeds were inadvertently disposed but then recovered by the licensee. On January 22, 2014, the Department was provided the actual activity amount and made the determination that this event qualifies as a reportable event under 10 CFR 20.2201(a)(1)(i). Event Description: On November 20, 2013, a box containing Pd-103 brachytherapy seeds was delivered to the Nuclear Medicine Department. On November 22, 2013, the Medical Physicist, prior to the implant procedure, noticed that all the seeds were not present. It was later acknowledged that all 90 seeds equaling 170 mCi of Pd-103 were inadvertently disposed. Cause of the Event: Human error. The seeds were not removed from the shipping box prior to the box being disposed of. Actions: On November 22, 2013, the Medical Physicist retrieved the missing box containing all the seeds. No exposure to anyone is expected while the seeds were missing. The regional office will further determine, with the licensee, the root cause of this event and the corrective actions to prevent this from reoccurring. Media attention: None at this time. Event Report ID No: PA140001 |