ENS 50620
ENS Event | |
|---|---|
05:00 Nov 4, 2014 | |
| Title | Agreement State Report - I-125 Seed Retrieved from Patient and Then Lost |
| Event Description | The following information was obtained from the State of New York via facsimile:
A radioactive source or I-125 seed used for localization in breast surgery was misplaced by the Pathology Department at Roswell Park Cancer Institute (DOH# 2923). This event occurred on Thursday, October 9, 2014 and the source was officially determined to be lost on November 4, 2014. Two breast localization seeds (I-125) were not extracted from a specimen on October 9, 2014 by a Clinical Pathology Fellow. The Pathology department did, however, receive written documentation that the seeds were removed from the patient and they were sent with the specimen to the Pathology Department. The seeds were not returned to Nuclear Medicine per Institute Policy. An extensive search and survey was conducted of Pathology, Nuclear Medicine and Environmental Services areas. One of the two seeds was discovered in trash removed from the Pathology department. Further search and surveys of these areas were repeated but to no avail. Trash and regulated medical waste were surveyed and inspected. Over the course of the next few weeks, Radiation Safety surveyed and explored all radioactive waste in an effort to locate the lost source. Aforementioned search and surveys were again conducted without discovery of the missing seed. It was believed that the missing source would eventually be located in Institute trash or more likely Institute radioactive waste. All Institute trash and waste is surveyed for radioactive material. The radioactive waste may be stored in various short and long-term storage locations. Unfortunately, the seed was never found and officially declared lost on November 4, 2014. Corrective Action and Recommendations: 1. The incident was reviewed and discussed with pertinent Pathology staff. A training oversight was discovered and Pathology Department Fellows are now trained to anticipate radioactive seeds in breast surgical specimens and to remove them prior to surgical specimen evaluation. (Required Corrective Action) 2. Radiation Safety and Environmental Services have emphasized the importance of monitoring all trash and regulated medical waste during the annual in-service conducted on August 6, 2014 and again on October 29, 2014. (Required Corrective Action) 3. Any further information regarding this matter will be communicated to the Bureau of Environmental Radiation Protection, NYS DOH [New York State Department of health]. (Required Corrective Action) New York State Event Report Number: NY-14-05 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 | |
|---|---|
| Roswell Park Cancer Institute Buffalo, New York (NRC Region 1) | |
| License number: | Nys #2923 |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+340.53 h14.189 days <br />2.027 weeks <br />0.466 months <br />) | |
| Opened: | Robert Snyder 09:32 Nov 18, 2014 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Nov 18, 2014 |
| 50620 - NRC Website | |
Roswell Park Cancer Institute with Agreement State | |
WEEKMONTHYEARENS 506202014-11-04T05:00:0004 November 2014 05:00:00
[Table view]Agreement State Agreement State Report - I-125 Seed Retrieved from Patient and Then Lost ENS 494012013-07-12T04:00:00012 July 2013 04:00:00 Agreement State Agreement State Report - Lost Iodine 125 Sealed Source Seed ENS 470132007-11-09T04:00:0009 November 2007 04:00:00 Agreement State Agreement State Report - P-32 Source Lost 2014-11-04T05:00:00 | |