ENS Event | |
|---|---|
05:00 Nov 20, 2015 | |
| Title | Agreement State Report - Lost Radioactive Seed |
| Event Description | The following was received from the Commonwealth of Pennsylvania via email:
The licensee discovered the event on November 23, 2015 and notified the Department [Commonwealth of Pennsylvania] on November 25, 2015. It is reportable as per 10 CFR 20.2201(a)(1)(ii). An iodine-125 (I-125) seed was used for radioactive seed localization of a breast lesion. After surgical excision of the breast tissue at an outpatient surgical center, the specimen was placed in a plastic bag and imaged radiographically to confirm the presence of the seed. The seed was noted to be at the edge of the specimen. The specimen was then transferred to a plastic container for transport to the main hospital pathology department. When the specimen was received at pathology, a survey indicated that there was no seed present. Radionuclide: I-125 Seed Manufacturer: Best Medical Model No.: 2301 Activity: 113 microCi The licensee assumes the seed became separated from the specimen and remained in the plastic bag which was disposed as biohazardous waste. A survey of the surgical center was performed, but the seed was not able to be located. A reactive inspection is planned by the Department. More information will be provided upon receipt. Event Report ID No: PA150030 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 | |
|---|---|
| University Of Pittsburgh Pittsburgh, Pennsylvania (NRC Region 1) | |
| License number: | PA-0190 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+126.57 h5.274 days <br />0.753 weeks <br />0.173 months <br />) | |
| Opened: | Joseph Melnic 11:34 Nov 25, 2015 |
| NRC Officer: | Dong Park |
| Last Updated: | Nov 25, 2015 |
| 51567 - NRC Website | |
University Of Pittsburgh with Agreement State | |
WEEKMONTHYEARENS 567702023-09-28T04:00:00028 September 2023 04:00:00
[Table view]Agreement State Agreement State - I-125 Seed Inadvertently Transected ENS 551392021-03-12T05:00:00012 March 2021 05:00:00 Agreement State Dose Received Was Less than Prescribed Dose ENS 515672015-11-20T05:00:00020 November 2015 05:00:00 Agreement State Agreement State Report - Lost Radioactive Seed ENS 482862012-09-06T04:00:0006 September 2012 04:00:00 Agreement State Agreement State Report - Yttrium-90 Microspheres Administered to the Wrong Treatment Site 2023-09-28T04:00:00 | |