ENS Event | |
|---|---|
04:00 Feb 17, 2026 | |
| Title | Lost I-125 Seed |
| Event Description | The following information was received from the Virginia Radioactive Materials Program (VRMP) via email:
On February 17, 2026, the licensee discovered and reported a lost I-125 [radioactive seed localization (RSL)] seed with an activity of 0.1186 mCi that was placed in a patient on February 16, 2026. Two seeds were implanted on February 16, 2026, and only one seed was found in surgery on February 17, 2026. A thorough search, including an extensive survey, was performed by the licensee, but the seed was not located. The seed meets the reporting requirement of 30 days from discovery. The licensee provided a report that included an acceptable root cause analysis and corrective action plan on February 26, 2026. The licensee determined the cause to be an inadequate procedure for implant/removal of RSL seeds and will revise their implant/removal procedure to better locate and account for all seeds placed. Virginia event report number: VA260002 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 | |
|---|---|
| University of Virginia Charlottesville, Virginia (NRC Region 1) | |
| License number: | 540-248-1 |
| Organization: | Virginia Rad Materials Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+684.7 h28.529 days <br />4.076 weeks <br />0.938 months <br />) | |
| Opened: | Sheila Nelson 15:42 Mar 17, 2026 |
| NRC Officer: | Josue Ramirez |
| Last Updated: | Mar 17, 2026 |
| 58206 - NRC Website
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University of Virginia with Agreement State | |
WEEKMONTHYEARENS 582062026-02-17T04:00:00017 February 2026 04:00:00
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