ENS 51058
ENS Event | |
|---|---|
16:11 May 7, 2015 | |
| Title | Lost Iodine-125 Seed |
| Event Description | On May 7, 2015, [Command Radiation Safety Officer (CRSO)] was notified by Brooke Army Medical Center [BAMC] Pathology that they could not find a I-125 seed. The seed was from a radioactive seed localization procedure for a breast biopsy. [The licensee's] Health Physics Service sent two personnel to investigate the loss and attempt to find the seed. After tracking the chain of custody and attempting to find the seed [the licensee] concluded that the seed was thrown away into the bio-hazard waste in pathology with the specimen tray.
On May 6, 2015, the pathologist transferred a biopsy specimen from a receiving tray to an examination tray. [The pathologist] then discarded the receiving tray in the bio-waste and used an RSL [radioactive seed localization] node seeker to confirm seed presence in the specimen. [The pathologist] misread the meter, marking on the seed tracking chain of custody form that the seed was present. [The licensee] examined the radiograph of the specimen, taken just before arriving at pathology, and found that the seed was on the edge of the biopsy specimen. [The licensee] believes the seed fell into the receiving tray upon transfer of the specimen and the seed was discarded along with that tray. The bio-hazard waste was disposed after this point, [approximately] 0600 [CDT] on May 7, 2015. On May 7, 2015, during clinical examination of the specimen and during the procedure to extract the seed, the pathologist could not find the seed. The RSO was called at this point and the investigation began. [The licensee] notified our environmental services branch and the waste disposal company to notify them that they may encounter a radioactive seed. The seed is I-125. The initial activity was 0.300 mCi on March 27, 2015, and was 0.185 mCi as of May 7, 2015. Today, BAMC Health Physics Service conducted an inventory and has accounted for all other I-125 RSL seeds besides the one mentioned in this email. [The licensee] will retrain the pathology section on proper procedures and conduct an in-service on how to read the RSL node seeker for confirming the presence of the seeds. [The licensee] will also discuss with pathology additional physical measures that can be implemented to ensure this does not happen again. [The CRSO] will send a full report along with memorandums and status on measures taken to prevent future occurrences. 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 | |
|---|---|
| Brooke Army Medical Center San Antonio, Texas (NRC Region 4) | |
| License number: | 42-01368-01 |
| Organization: | Brooke Army Medical Center |
| Reporting | |
| 10 CFR 20.2201(a)(1)(ii) | |
| Time - Person (Reporting Time:+19.7 h0.821 days <br />0.117 weeks <br />0.027 months <br />) | |
| Opened: | David Byrd 11:53 May 8, 2015 |
| NRC Officer: | John Shoemaker |
| Last Updated: | May 8, 2015 |
| 51058 - NRC Website | |
Brooke Army Medical Center with 10 CFR 20.2201(a)(1)(ii) | |
WEEKMONTHYEARENS 539922019-03-13T05:00:00013 March 2019 05:00:00
[Table view]10 CFR 20.2201(a)(1)(ii) Lost I-125 Seeds ENS 515962015-11-17T06:00:00017 November 2015 06:00:00 10 CFR 20.2201(a)(1)(ii) Lost Iodine-125 Seed ENS 510582015-05-07T16:11:0007 May 2015 16:11:00 10 CFR 20.2201(a)(1)(ii) Lost Iodine-125 Seed 2019-03-13T05:00:00 | |