ENS Event | |
|---|---|
04:00 Jul 12, 2013 | |
| Title | Agreement State Report - Lost Iodine 125 Sealed Source Seed |
| Event Description | The following information was received from the New York State Department of Health (NYS DOH) via facsimile:
The source was a seed source for Breast Localization Procedures. The medical procedure occurred on July 12, 2013. A tissue specimen was removed from a patient. The localization seed was identified and removed from the specimen post-surgery. The seed was not returned to the Nuclear Medicine Department per institute policy, which initiated a facility search for the missing RAM [radioactive material]. Immediate actions included conducting extensive facility area surveys for several weeks. The source was declared officially lost on August 29, 2013. The root cause involved a failure to follow the facility policy. The seed was allowed to become lost, after it had been properly identified. Corrective actions involve an incident review with the pertinent staff and an in-service refresher training for all staff. The facility has been informed by NYS DOH that this event should have been reported immediately on July 12, 2013. Manufacturer, Best Medical International, Inc., Model No. 2301 I-125, Activity, 140 microCuries. New York State Report ID No. NY-13-05 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 |
| Where | |
|---|---|
| Roswell Park Cancer Institute Buffalo, New York (NRC Region 1) | |
| License number: | Nys #2923 |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1973.87 h82.245 days <br />11.749 weeks <br />2.704 months <br />) | |
| Opened: | Robert Snyder 09:52 Oct 2, 2013 |
| NRC Officer: | John Shoemaker |
| Last Updated: | Oct 2, 2013 |
| 49401 - NRC Website | |
Roswell Park Cancer Institute with Agreement State | |
WEEKMONTHYEARENS 506202014-11-04T05:00:0004 November 2014 05:00:00
[Table view]Agreement State Agreement State Report - I-125 Seed Retrieved from Patient and Then Lost ENS 494012013-07-12T04:00:00012 July 2013 04:00:00 Agreement State Agreement State Report - Lost Iodine 125 Sealed Source Seed ENS 470132007-11-09T04:00:0009 November 2007 04:00:00 Agreement State Agreement State Report - P-32 Source Lost 2014-11-04T05:00:00 | |