ENS Event | |
|---|---|
04:00 Sep 28, 2023 | |
| Title | Agreement State - I-125 Seed Inadvertently Transected |
| Event Description | The following information was provided by the Pennsylvania Bureau of Radiation Protection via email:
On September 28, 2023, staff from Magee Pathology department called the [University of Pittsburgh] radiation safety office to report that they had accidentally transected an I-125 seed used for radioactive seed localization (RSL) in breast tissue during the pathology processing in the laboratory. The seed was a Best Medical International Model 2301 containing 169 microcuries of I-125. Two staff members were involved, and they were told to sequester in the room until personnel from radiation safety could respond. Shortly after, radiation safety personnel performed surveys to determine the extent of the contamination. No personnel contamination was observed. All contamination was discovered in waste material and on the tissue samples. The transected seed was contained. The radiation safety office took possession of the damaged seed and all radioactive waste. At the time of reporting, it is estimated that approximately 50 percent of the activity was lost to open contamination, which is greater than 1 annual limit on intake (ALI) of I-125, and therefore reached the criteria for [10 CFR] 22.2202 reportability. Workers had bioassays performed for thyroid exposure and all returned negative. PA event report ID: PA230028 |
| Where | |
|---|---|
| University Of Pittsburgh Pittsburgh, Pennsylvania (NRC Region 1) | |
| License number: | PA-0190 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+102.32 h4.263 days <br />0.609 weeks <br />0.14 months <br />) | |
| Opened: | John Chippo 10:19 Oct 2, 2023 |
| NRC Officer: | Ernest West |
| Last Updated: | Oct 2, 2023 |
| 56770 - NRC Website | |
University Of Pittsburgh with Agreement State | |
WEEKMONTHYEARENS 567702023-09-28T04:00:00028 September 2023 04:00:00
[Table view]Agreement State Agreement State - I-125 Seed Inadvertently Transected ENS 551392021-03-12T05:00:00012 March 2021 05:00:00 Agreement State Dose Received Was Less than Prescribed Dose ENS 515672015-11-20T05:00:00020 November 2015 05:00:00 Agreement State Agreement State Report - Lost Radioactive Seed ENS 482862012-09-06T04:00:0006 September 2012 04:00:00 Agreement State Agreement State Report - Yttrium-90 Microspheres Administered to the Wrong Treatment Site 2023-09-28T04:00:00 | |