ENS Event | |
|---|---|
04:00 Jun 25, 2020 | |
| Title | Agreement State Reort - Missing I-125 Seed |
| Event Description | The following was received via fax from the New York State Department of Health:
On July 7, 2020, the [New York State] Department [of Health] was notified of a missing Iodine-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 142 microCuries) at Roswell Park Cancer Institute in Buffalo, New York. An lodine-125 localization seed was removed from a patient in a procedure that took place on June 25, 2020, and is believed to have been lost in the intraoperative frozen section room in surgery. The RSO [Radiation Safety Officer] was informed of the missing seed on June 29, 2020. The facility conducted searches and surveys of the Surgery, Pathology, Radiation Safety and Environmental Services areas. Trash and regulated medical waste were also surveyed and inspected. It is believed that the seed will be recovered from the facility's regular trash, but more likely in the facility's radioactive waste. New York State Event Report Number: NYDOH 20-02 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 | |
|---|---|
| New York State Dept. Of Health Buffalo, New York (NRC Region 1) | |
| License number: | 2923 |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1188.6 h49.525 days <br />7.075 weeks <br />1.628 months <br />) | |
| Opened: | Daniel J. Samson 16:36 Aug 13, 2020 |
| NRC Officer: | Brian P. Smith |
| Last Updated: | Aug 13, 2020 |
| 54836 - NRC Website | |
New York Department of Health with Agreement State | |||
WEEKMONTHYEARENS 562072022-07-20T04:00:00020 July 2022 04:00:00 Agreement State Lost Licensed Material (Medical Seeds) ENS 548942020-09-09T04:00:0009 September 2020 04:00:00 Agreement State | Agreement State Report - Medical Event - Underdose ENS 549022020-08-11T04:00:00011 August 2020 04:00:00 Agreement State | Agreement State Report - Lost I-125 Seed ENS 548362020-06-25T04:00:00025 June 2020 04:00:00 Agreement State Agreement State Reort - Missing I-125 Seed ENS 545822020-01-27T04:00:00027 January 2020 04:00:00 Agreement State Agreement State Report - Missing Iodine-125 Seed ENS 454802009-11-03T05:00:0003 November 2009 05:00:00 Agreement State Agreement State Report Involving Leaking Irradiator Source 2022-07-20T04:00:00 [Table view] | |