ENS Event | |
|---|---|
05:00 Oct 5, 2018 | |
| Title | Agreement State Report - Missing I-125 Seed |
| Event Description | The following report was received via fax:
On 11/28/2018 the Department [New York State Department of Health] was notified of a missing I-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 186 microCuries) at Roswell Park Cancer Institute in Buffalo, New York. Two lodine-125 breast localization seeds were placed into a patient on September 20, 2018 and removed on September 28, 2018. One seed was placed in a specimen container with the specimen, and the other seed was placed into a separate specimen container. Surgery has documentation that both seeds were sent to Pathology in separate containers; however, only one was returned to the Nuclear Medicine Department on October 4, 2018. The RSO was informed on October 5, 2018. The facility conducted searches and surveys of the Surgery, Pathology, Nuclear Medicine and Environmental Services areas, but could not locate the missing seed. Trash and regulated medical waste were also surveyed and inspected. Searches and surveys were repeated, but the seed was not found. It is believed that the seed was disposed of as regulated medical waste or in regular trash. New York State ID: NYSDOH - 18-04 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 Corp Buffalo, New York (NRC Region 1) | |
| License number: | 2923 |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+2647.82 h110.326 days <br />15.761 weeks <br />3.627 months <br />) | |
| Opened: | Daniel Samson 13:49 Jan 23, 2019 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Jan 23, 2019 |
| 53843 - NRC Website | |
Roswell Park Cancer Institute Corp with Agreement State | |
WEEKMONTHYEARENS 538432018-10-05T05:00:0005 October 2018 05:00:00
[Table view]Agreement State Agreement State Report - Missing I-125 Seed 2018-10-05T05:00:00 | |