ENS 55657
ENS Event | |
|---|---|
06:00 Jul 26, 2019 | |
| Title | Lost Brachytherapy Seed |
| Event Description | The following information was received from the state of Minnesota via email:
It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO. Abbott Northwestern Hospital (ANH) reported the loss of a 6.845 MBq (185 microCi) I-125 localization seed (Best Medical International model 2301, lot #48287) from the ANW Piper Breast Center on 7/26/2019. A tissue specimen containing the seed was removed from a patient and transported to pathology. The pathology assistant removed the seed from the specimen and placed it adjacent to the specimen in the workspace. After the pathologist and surgeon examined the specimen, the assistant noticed that the seed was missing. ANH conducted radiation surveys of the surrounding area (staff clothing, shoes, and adjacent hallways), but did not locate the seed. ANH believes that while the pathologist and surgeon were examining the specimen, the seed was bumped into the sink and washed down the drain. Corrective actions included procedure modification and providing additional training to personnel. During subsequent procedures, pathology staff will place the seed into a lead container before the pathologist and surgeon examine the specimen. Minnesota event number: 190004 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 | |
|---|---|
| Abbott Northwestern Hospital Minneapolis, Minnesota (NRC Region 3) | |
| License number: | 1007 |
| Organization: | Minnesota Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+20983.28 h874.303 days <br />124.9 weeks <br />28.743 months <br />) | |
| Opened: | Sherrie Flaherty 14:17 Dec 16, 2021 |
| NRC Officer: | Mike Stafford |
| Last Updated: | Dec 16, 2021 |
| 55657 - NRC Website | |
Abbott Northwestern Hospital with Agreement State | |
WEEKMONTHYEARENS 556572019-07-26T06:00:00026 July 2019 06:00:00
[Table view]Agreement State Lost Brachytherapy Seed ENS 511002015-05-29T15:30:00029 May 2015 15:30:00 Agreement State Agreement State Report - Medical Treatment to Incorrect Lobe of the Liver ENS 493312013-09-06T05:00:0006 September 2013 05:00:00 Agreement State Agreement State Report - Dose Delivered to Wrong Site ENS 476482012-02-02T06:00:0002 February 2012 06:00:00 Agreement State Agreement State Report - Y-90 Dosage to Unintended Areas ENS 466832011-03-17T05:00:00017 March 2011 05:00:00 Agreement State Agreement State Report - Yttrium-90 Microspsheres Administered at 150% of Prescribed Dose 2019-07-26T06:00:00 | |