ENS Event | |
|---|---|
04:00 Apr 14, 2020 | |
| Title | Missing Iodine-125 Seed |
| Event Description | The following information was received via facsimile:
On April 29, 2020, the Department [New York State Department of Health, Bureau of Environmental Radiation Protection] was notified of a missing I-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 220 microCuries) at Roswell Park Cancer Institute in Buffalo, New York. In this incident, two seeds were placed into a patient on 4/10/2020 and removed on 4/14/2020. One of the two seeds was lost by the attending surgeon. An extensive survey of the patient was performed to verify that the seed was not in the patient and the Nuclear Medicine Department was notified. A survey of the operating room (OR) suite was conducted and the seed was not recovered. The Radiation Safety Office was notified, another survey of the OR was performed, again the seed was not recovered. The patient also had a lymphoscintigraphy with Tc-99m so the surgical trash that was still in the room was sequestered. After three days, the trash was surveyed and examined but the seed was not recovered. Searches and surveys were performed in surgery, pathology, radiation safety and environmental service areas. Trash and regulated medical waste were also surveyed and inspected. Ultimate disposition of the source is unknown and it is possible that the source may still be recovered. New York State Event Report ID No.: NYDOH - 20-05 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 Corp. Buffalo, New York (NRC Region 1) | |
| License number: | 2923 |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+4281.7 h178.404 days <br />25.486 weeks <br />5.865 months <br />) | |
| Opened: | Daniel Samson 13:42 Oct 9, 2020 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Oct 9, 2020 |
| 54941 - NRC Website | |
Roswell Park Cancer Institute Corp. with Agreement State | |
WEEKMONTHYEARENS 549412020-04-14T04:00:00014 April 2020 04:00:00
[Table view]Agreement State Missing Iodine-125 Seed ENS 539152019-02-18T05:00:00018 February 2019 05:00:00 Agreement State Agreement State Report - Lost Iodine-125 Localization Seed 2020-04-14T04:00:00 | |