Center for Diagnostic Pathology discovered a lost source on June 3. It was a seed that was implanted in breast tissue on May 24 and removed on May 25. Two specimens with seeds were removed and one was processed in the Operating Room. The pathologist thought the seed was removed but it was discovered that a biopsy clip was mistaken for the seed. The clip was sent to the lab instead and when the lab manager did the inventory on June 2, they could not find the seed. On June 3 a survey could not locate the seed. They believe the seed was left in the specimen that was frozen to be sliced by histology. They could see in the slices where the seed was, but they could not find the seed and believe it was dislodged during the slicing and collected with the rest of the waste to be incinerated by Daniels. That waste was picked up June 1. It was stated that due to the source being low energy, the exposure risk was low.
A follow up investigation is pending."
Florida incident number: Not yet assigned.
- * * UPDATE ON 6/08/21 AT 0800 EDT FROM MATTHEW SENSION TO LLOYD DESOTELL * * *
Florida Department of Health re-sent the incident report and provided the incident number.
Florida Event Number: FL21-075
Notified R1DO (Ferdas)(email), ILTAB (email) and NMSS Event Notifications (email).
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