ENS 54550
ENS Event | |
|---|---|
05:00 Jan 18, 2019 | |
| Title | Agreement State Report - Improper Disposal of I-125 Seed |
| Event Description | The following is a summary of emails received from the Georgia Department of Natural Resources (the state):
On 01/18/2019, the licensee performed a Radioactive Seed Localization (RSL) using 81 microCi of I-125. The tissue and seed were transported to pathology where the pathologist misidentified the seed as a straight clip-non-radioactive and the material was designated for disposal. The Nuclear Technologist realized on 02/06/2019, through paperwork, that the seed could not be accounted for and had improperly gone out through the ordinary waste process at the hospital. On 03/04/2019, the state's reactive inspection report found that the RSL procedure was a two seed implantation. A documentation problem occurred when two separate I-125 seed tracking documents were used instead of one. When the tissue containing the seeds was excised and taken to pathology in a cup, only a single document showing one seed implant made it to pathology. The second document did not arrive, so pathology was unaware that there were two seed implants. This led to one of the seeds being mistaken for a clip. The cup that the tissue was transported in was surveyed at pathology and there was the expected readout, which was attributed to a single seed. Corrective actions include to document seeds acquired for implantation on a single sheet of paper. Efforts were being made to discontinue the RSL program and replace it with a radiofrequency seed localization system that involves no radioactivity. The incident was closed on 03/04 2019. Incident Report No.: GA-2019-10 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 | |
|---|---|
| Piedmont Fayette Hospital Fayetteville, Georgia (NRC Region 1) | |
| License number: | GA 1340-1 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+9745.9 h406.079 days <br />58.011 weeks <br />13.35 months <br />) | |
| Opened: | Gregory Reese 06:54 Feb 28, 2020 |
| NRC Officer: | Ossy Font |
| Last Updated: | Feb 28, 2020 |
| 54550 - NRC Website | |
Georgia Radioactive Material Program with Agreement State | ||||
WEEKMONTHYEARENS 560652022-08-23T16:00:00023 August 2022 16:00:00 Agreement State Lost Radioactive Portable Gauge ENS 548822020-09-02T04:00:0002 September 2020 04:00:00 Agreement State | Agreement State Report - Medical Event - Underdose ENS 548792020-08-27T04:00:00027 August 2020 04:00:00 Agreement State | Agreement State Report - Loss of Medical Seed After Removal from Patient ENS 548172020-07-21T04:00:00021 July 2020 04:00:00 Agreement State | ENS 546942020-05-04T04:00:0004 May 2020 04:00:00 Agreement State Agreement State Report - Patient Underdose ENS 546622020-03-31T04:00:00031 March 2020 04:00:00 Agreement State Agreement State Report - Loss of Iodine-125 Seed ENS 541102019-06-11T04:00:00011 June 2019 04:00:00 Agreement State Agreement State Report - Patient Under Dosage Due to Air Being Trapped in the Delivery Line ENS 545492019-05-02T05:00:0002 May 2019 05:00:00 Agreement State Agreement State Report - Broken Density Gauge Shutter ENS 539962019-04-03T04:00:0003 April 2019 04:00:00 Agreement State Agreement State Report - Underdose Administration of Y-90 Theraspheres ENS 545502019-01-18T05:00:00018 January 2019 05:00:00 Agreement State Agreement State Report - Improper Disposal of I-125 Seed ENS 545412018-12-18T05:00:00018 December 2018 05:00:00 Agreement State Agreement State Report - Leaking Promethium-147 Source ENS 545652018-06-29T05:00:00029 June 2018 05:00:00 Agreement State Agreement State Report - Lost Iodine-125 Seed ENS 545372018-04-03T05:00:0003 April 2018 05:00:00 Agreement State Agreement State Report - Stuck Open Shutter ENS 545632017-11-06T05:00:0006 November 2017 05:00:00 Agreement State Agreement State Report - Leaking Cesium-137 Source ENS 546442017-06-09T04:00:0009 June 2017 04:00:00 Agreement State Agreement State Report - Stuck Shutter ENS 545642016-08-09T05:00:0009 August 2016 05:00:00 Agreement State Agreement State Report - Lost I-125 Source 2022-08-23T16:00:00 [Table view] | |