ENS Event | |
|---|---|
04:00 Jun 22, 2022 | |
| Title | Missing I-125 Seed |
| Event Description | The following information was provided by the licensee via email:
On June 22, 2022, West Virginia University Radiation Safety Department discovered that one Iodine-125 seed (Isoaid Model IAl-125A, titanium capsule sealed source, seed lot number 202280796) used in a Radioactive Seed Localization procedure was missing. The seed, with an activity of 268 microCi, was implanted into a lesion in the patient's right breast on June 16, 2022. A second seed, with the same activity, was implanted into the same lesion in the patient's right breast on the same day. A third seed, with the same activity, was implanted into a lesion in the patient's left breast on the same day. The surgery to remove the lesions was completed on the same day. On June 21, 2022, a Radiation Safety specialist picked up 2 seeds from the patient in question along with 7 seeds from different patients. At this time the Radiation Safety specialist did not have seed implantation records for all the seeds retrieved as they were not available at the Breast Care Center. On June 22, 2022, the specialist retrieved the seed implantation records and noted that the patient in question had a total of three seeds implanted and reported the seed as missing to the Radiation Safety Department Manager. An investigation determined that the seed arrived in the Pathology Gross Room but was likely inadvertently discarded in the trash or flushed down the sink. 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 | |
|---|---|
| West Virginia University Morgantown, West Virginia (NRC Region 1) | |
| License number: | 47-23066-02 |
| Organization: | West Virginia University |
| Reporting | |
| 10 CFR 20.2201(a)(1)(ii) | |
| Time - Person (Reporting Time:+562 h23.417 days <br />3.345 weeks <br />0.77 months <br />) | |
| Opened: | Stephen Root 14:00 Jul 15, 2022 |
| NRC Officer: | Lloyd Desotell |
| Last Updated: | Sep 8, 2022 |
| 55994 - NRC Website | |
West Virginia University with 10 CFR 20.2201(a)(1)(ii) | |
WEEKMONTHYEARENS 559942022-06-22T04:00:00022 June 2022 04:00:00
[Table view]10 CFR 20.2201(a)(1)(ii) Missing I-125 Seed 2022-06-22T04:00:00 | |