The following was received from the
Washington State Department of Health (the department) via email:
A hospital [Baptist Hospital of Miami, Miami, FL.] shipped unused brachytherapy seeds and GammaTiles back to the manufacturer, who is GT Medical Technologies. The manufacturer surveyed the returned package and measured about 14.6 mR/hour on the outside of the package instead of the typical reading of about 1.5 mR/hour.
The manufacturer opened the package and found that the hospital did not follow the written instructions on how to pack return shipments. The top piece of foam packaging was not included in the package.
The manufacturer found that, during transportation, two glass vials containing [cesium-131] reference brachytherapy seeds had escaped from their shielded storage container. The glass vials did not break and the seeds were still inside them. It was the unshielded seeds that caused the elevated reading on the outside of the package.
The manufacturer notified the hospital, the [common] carrier, and the regulator [(the department)].
The department expects to obtain additional information tomorrow about this event, and will provide an updated event report.
Washington Event Number: WA-24-008