ENS 54019
ENS Event | |
|---|---|
05:00 Apr 19, 2019 | |
| Title | Agreement State Report - Lost and Recovered I-125 Source |
| Event Description | The following information was obtained from the state of Illinois via email:
The RSO [radiation safety officer] at the University of Chicago [Hospital], called to report that the University received one lsoAid, Model IAl-125A, I-125 source for a seed localization procedure. It had an activity of 271 microCuries when implanted in the patient on Thursday, April 18, 2019. On Friday, the patient's tissue [containing the I-125 seed was excised] and sent to pathology for evaluation. During all steps, the individuals involved reported that they measured appropriate dose rates from the seed. The Pathology technician was using scissors on the patient's tissue and the seed popped out of the specimen and fell into the sink. The seed was recovered before it went down the drain. Surveys of the sink show no contamination or dose rate measurements. The radiation safety staff measured the recovered source with both a survey instrument and a gamma counter, and the source has no measureable dose rate. The patient was surveyed and it was determined that the source [was] not in the patient. A review of the SSDR [sealed source and device registry] sheet has determined that this source contains I-125 adsorbed on a silver rod which is further encased in the outer capsule. The outer capsule measures 3.0 mm x 0.5 mm and there are no visible signs that the source was cut. They plan to take the seed for an x-ray today to determine if the inner rod is missing and to see if there are obvious signs that the outer capsule was breached. UPDATE: The I-125 seed was found intact in the sink trap. The source that was initially believed to be the subject seed was from another patient and was a three-year-old prostate seed that had decayed to background. NMED Item Number: IL190012 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 Chicago Hospital Chicago, Illinois (NRC Region 3) | |
| License number: | IL-01678-02 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+84.63 h3.526 days <br />0.504 weeks <br />0.116 months <br />) | |
| Opened: | Mary Burkhart 17:38 Apr 22, 2019 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Apr 22, 2019 |
| 54019 - NRC Website | |
University Of Chicago Hospital with Agreement State | |
WEEKMONTHYEARENS 553102021-06-15T05:00:00015 June 2021 05:00:00
[Table view]Agreement State Medical Event - Underdose ENS 540192019-04-19T05:00:00019 April 2019 05:00:00 Agreement State Agreement State Report - Lost and Recovered I-125 Source ENS 531272017-12-15T06:00:00015 December 2017 06:00:00 Agreement State Agreement State Report - Underdose ENS 422072005-09-12T06:00:00012 September 2005 06:00:00 Agreement State Illinois Agreement State Report - Medical Misadministration 2021-06-15T05:00:00 | |