ENS Event | |
|---|---|
04:00 May 2, 2019 | |
| Title | Agreement State Report - I-125 Seed Lost |
| Event Description | The following information was received via e-mail:
On 5/1/19 a patient had two [radioactive seed localization] RSL seeds [200 microCuries; I-125] implanted. The same patient returned the following day for an explant procedure. At that time, it was discovered that one seed was missing from the patient. The licensee confirmed through recorded imaging, consultation with the surgeon, patient surveys, and detailed surveys of the implant site and the explant site that the most likely area where the seed was lost was somewhere in between when the patient left the implant site and returned to the explant site the following day. North Carolina Radioactive Materials Branch has started an investigation that is ongoing at this time. This event is reportable per 20.2201(a)(1)(ii) - Lost, stolen, or missing licensed material in a quantity greater than 10 times the Appendix C quantities. North Carolina Tracking ID: NC 190016 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 | |
|---|---|
| Moses Cone Hospital Greensboro, North Carolina (NRC Region 1) | |
| License number: | 041-0021-1 |
| Organization: | Nc Div Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+35.5 h1.479 days <br />0.211 weeks <br />0.0486 months <br />) | |
| Opened: | Travis Cartoski 15:30 May 3, 2019 |
| NRC Officer: | Jeffrey Whited |
| Last Updated: | May 3, 2019 |
| 54045 - NRC Website | |
Moses Cone Hospital with Agreement State | |
WEEKMONTHYEARENS 540452019-05-02T04:00:0002 May 2019 04:00:00
[Table view]Agreement State Agreement State Report - I-125 Seed Lost 2019-05-02T04:00:00 | |