ENS 51893

v t e ENS Event
07:00 Apr 27, 2016
Title	Agreement State Report - Implanted Iodine 125 Seed Not Accounted for
Event Description	The following was received from Arizona via email: On April 27th, the licensee [Mayo Clinic Arizona] discovered that one (1) I-125 seed was missing with an approximate activity of 0.3 millicuries. The breast tissue from a patient was analyzed by the licensees' surgical staff on April 26th and one seed was removed and then brought down to the nuclear medicine department on the morning of the 27th. The nuclear medicine staff quickly realized that there should have been two seeds, since two seeds were initially implanted. The licensee's radiation safety staff surveyed both the hospital surgical path area as well as the pathology/histology area and no source was discovered. The investigation into this event is ongoing. The U.S. NRC and Arizona Governor's office are being notified of this event. Arizona Incident # 16-007 A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

ENS 51893 +/-
Where
Mayo Clinic Arizona Phoenix, Arizona (NRC Region 4)
License number:	AZ 07-448
Organization:	Arizona Radiation Regulatory Agency
Reporting

Agreement State
Time - Person (Reporting Time:+78.88 h3.287 days <br />0.47 weeks <br />0.108 months <br />)
Opened:	Brian Goretzki 13:53 Apr 30, 2016
NRC Officer:	Daniel Mills
Last Updated:	Apr 30, 2016
51893 - NRC Website
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v t e Emergency Notification System
Mayo Clinic Arizona with Agreement State
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