ENS 55944
ENS Event | |
|---|---|
07:00 Jun 14, 2022 | |
| Title | Agreement State Report - Lost Then Found I-125 Seed |
| Event Description | The following information was received via E-mail:
On 6/14/22, one Theragenics, I-125 brachytherapy seed (0.501 mCi) from the inventory was discovered missing. It was one of 10 spare seeds used for a patient prostate implant should they be needed. The inventory of concern was that required for a patient who was implanted with 88 seeds using 16 needles as planned. He did not need any of the spare seeds for his implant. In accord with our standard procedure, five of the 10 spare seeds were prepared in spare needles by one of our radiation oncology dosimetrists, one seed per needle, on Monday, 06/13/22. All prepared needles and loose seeds remained in the hot lab (SP 22244) until the patient's surgery. This means that five loose I-125 seeds should have remained in their transport vial in the hot lab (SP 2244) adjacent to the surgery room (SP 2245). However, when preparing to return the five spare needle prepared seeds to the transport vial, post patient implant, it was evident that there were only four rather than the expected five loose seeds in the vial. I surveyed the hot lab (SP 2244) but could not locate the missing seed in the hot lab or its surrounding area. The five spare needle prepared seeds were returned to the transport vial for a total of nine seeds rather than the inventory of 10. This vial was taken to the radiation oncology hot lab safe. Several surveys were performed of the Surgery Pavilion area (SP 2244) but the seed was not found. On 6/15/2022, the missing I-125 seed (0.501 mCi) was found and returned with the other loose seeds to the 'Medak' vial now located in the radiation oncology hot lab. On an inspired guess, the dosimetrist returned to the SP 2244 hot lab in the prostate pavilion and in a high cupboard searched a steel container used for sterilizing all 10 loose seeds before creating the five spare needles. This is where the missing seed was found. As corrective actions, the unused seeds will be visually counted and the checklist updated to include this process. Washington Incident Number: WA-22-015 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 Washington Seattle, Washington (NRC Region 4) | |
| License number: | C001-1 |
| Organization: | Wa Office Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+32.28 h1.345 days <br />0.192 weeks <br />0.0442 months <br />) | |
| Opened: | Raj Maharjan 15:17 Jun 15, 2022 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Jun 15, 2022 |
| 55944 - NRC Website | |
University Of Washington with Agreement State | |
WEEKMONTHYEARENS 561932022-10-25T07:00:00025 October 2022 07:00:00
[Table view]Agreement State Leaking Sealed Source ENS 559442022-06-14T07:00:00014 June 2022 07:00:00 Agreement State Agreement State Report - Lost Then Found I-125 Seed ENS 556772021-12-23T08:00:00023 December 2021 08:00:00 Agreement State Underdosing of Patient with YTTRIUM-90 Microspheres ENS 551922021-04-09T07:00:0009 April 2021 07:00:00 Agreement State Patient Underdose ENS 540132019-04-15T07:00:00015 April 2019 07:00:00 Agreement State Agreement State Report - Leaking Intravascular Brachytherapy Device Identified ENS 518792016-04-20T07:00:00020 April 2016 07:00:00 Agreement State Agreement State Report - Missing Static Ionization Source ENS 518492016-03-31T07:00:00031 March 2016 07:00:00 Agreement State Agreement State - Package Containing 40 Millicuries of Ni-63 Reported Missing ENS 511762015-06-19T07:00:00019 June 2015 07:00:00 Agreement State Agreement State Report - Medical Under Dose ENS 495402013-11-12T08:00:00012 November 2013 08:00:00 Agreement State Agreement State Report - Radioactive Material Unaccounted for ENS 469312011-03-31T01:00:00031 March 2011 01:00:00 Agreement State Agreement State Report - Extremity Overexposure During Laboratory Work ENS 411822004-11-05T08:00:0005 November 2004 08:00:00 Agreement State Agreement State Report Due to Loss of Iodine-125 Calibration Seeds 2022-06-14T07:00:00 | |