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The following report was received from the Arizona Department of Health Services (Department) via email: On November 25, 2019, the Department was notified of a lost I-125 seed. The licensee believes that the seed was most likely lost in pathology on November 21, 2019. The Department is continuing to investigate the event. Arizona Incident: 19-028.

• * * UPDATE SENT BY BRAIN GORETZKI RECEIVED BY RICHARD SMITH ON NOVEMBER 26, 2019 AT 9:45 EST * * *

The following was received via email from the state of Arizona: Vender for the I-125 seed was Isoaid, description of the seed was 5 cm stranded seed, Lot Number 63917-5, and activity was 0.197mCi I-125. Notified: R4DO (Pick). 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

The following was received from the state of Arizona via e-mail: The (Arizona Department of Health Services) received notification from the licensee that an individual received a whole body exposure of approximately 290 Rem for the month of March. The individual is believed to be an x-ray technologist that works in the operating room. It is unknown at this time if the individual may also work with radioactive materials. The Department has requested additional information and continues to investigate the event. Additional information will be provided as it is received in accordance with SA-300. Arizona incident Number 19-008. A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

• * * UPDATE ON 4/26/19 AT 1134 EDT, FROM BRIAN GORETZKI TO JOANNA BRIDGE * * *

The following was received from the state of Arizona via e-mail: This correspondence is a follow-up to the notification sent (on 4/25/19) regarding an approximate 290 Rem whole body exposure. It was determined through inspector interviews and procedure logs that the individual is an x-ray technologist and does not work with radioactive materials. The individual is the lead (certified radiation technologist) in an (operating room) department of a hospital performing 6-7 fluoroscopic procedures per day. It is believed that the actual exposure was just to the badge and not to the person. Notified R4 RDO (Young), NMSS Events (email), NMSS Director (Kock), and INES (Milligan).

The following information was received via E-mail: At approximately 1300 MST on July 26, 2016, the licensee contacted the Agency (Arizona Radiation Regulatory Agency) and reported that a 0.4 millicurie Iodine-125 source, which was being used for localization, was discovered missing. An initial radiation survey of the department did not locate the source. The licensee does not know the exact date or time that the I-125 source went missing. The agency is continuing to investigate the event. The Governor's Office and NRC are being notified of this event. Arizona First Notice Number: 16-013 Notified Mexico via E-mail.

• * * UPDATE AT 1540 EDT ON 8/16/16 FROM BRIAN GORETZKI TO JEFF HERRERA * * *

The following update was received from the Arizona Radiation Regulatory Agency via email: On August 12, 2016, the licensee notified the Agency (Arizona Radiation Regulatory Agency) that the initial notification was incorrect and that a 0.5 (micro Curie) Cs-137 button source had been lost and not an I-125 seed. The Administrative Director stated that he had assumed it was an I-125 seed because the lost source was from pathology but he did not clarify. Notified R4DO (Proulx), NMSS (email), ILTAB (email), MEXICO(email). 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

The following was received from Arizona via email: On April 27th, the licensee (Mayo Clinic Arizona) discovered that one (1) I-125 seed was missing with an approximate activity of 0.3 millicuries. The breast tissue from a patient was analyzed by the licensees' surgical staff on April 26th and one seed was removed and then brought down to the nuclear medicine department on the morning of the 27th. The nuclear medicine staff quickly realized that there should have been two seeds, since two seeds were initially implanted. The licensee's radiation safety staff surveyed both the hospital surgical path area as well as the pathology/histology area and no source was discovered. The investigation into this event is ongoing. The U.S. NRC and Arizona Governor's office are being notified of this event. Arizona Incident # 16-007

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

The following information was obtained from the State of Arizona via email: At approximately 0800 (MST) on July 1, 2015, the licensee reported that two (2) 0.256 millicurie Iodine-125 seeds were potentially lost on June 24, 2015. The licensee stated that while implanting 84 I-125 seeds into a patient in the operating room, the doctor realized that one of the syringes, which was supposed to have two (2) I-125 seeds in it, was empty. The licensee surveyed the entire operating room and hot lab but did not locate the seeds. The manufacturer was also contacted in an attempt to see if the syringe was shipped to the licensee without the seeds in it. The Agency (Arizona Radiation Regulatory Agency) is investigating the event. The Governor's Office is being notified of this event. Arizona First Notice: 15-012

• * * UPDATE ON 7/2/15 AT 1741 EDT FROM BRIAN GORETZKI TO JEFF HERRERA * * *

The following update was provided by the Arizona Radiation Regulatory Agency via email: On July 2, 2015, the two lost seeds were discovered to be actually implanted into the patient. After a review of the new CT scan, the licensee was able to identify that all 84 seeds were in the patient. Notified the R4DO (Okeefe) and NMSS Events (via email). 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