ENS 51980

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v t e ENS Event
04:00 Apr 26, 2016
Title	Agreement State Report - Missing Source
Event Description	The following information was received by the State of Ohio via email: On 4/26/2016, Physics reported that during prepping a return shipment the dosimetrist discovered one I-125 prostate seed was missing from the lead pig. The lead pig contained loose/broken seeds from the implant performed on 4/6/2016. There were three seeds in the vial where there should've been four. The RSO interviewed the dosimetrist and the physicist who worked this case. Inventory log and loading summary were audited. Inventory log recorded 28 seeds returned to storage. Of the 28 seeds returned, 24 were in the cartridge and 4 were loose/broken seeds stored in the lead pig. It was not until 4/26/2016 when Physics discovered only 3 seeds were in the lead pig. Radiation surveys records were audited. Surveys were performed accordingly and readings were background level. At this time, the seed has not been located. Based on the information provided by the medical physicist and the dosimetrist, it is still unclear as to precisely determine when and how the seed became missing. Licensee believes there was no radiation exposure to the individual(s) involved. To prevent a recurrence, two individuals shall visually count the seeds in the lead pig before leaving the operating room. Furthermore, two individuals shall review loading summary to confirm all seeds are accounted for. Licensee has previously observed that 1-125 seeds are prone to static buildup and have the tendency to cling to plastic, glass walls, and other surfaces. Most likely, the lost seed was swept up and discarded with normal trash. Based on the relatively low activity and low energy of the 1-125 seed and measured background readings in the operating room, there was no radiation exposure to workers or members of the public due to this loss. Source/Radioactive Material: Sealed source brachytherapy Manufacturer: Theragenics Model Number: AgX100 Radionuclide: I-125, 0.000396 Ci Ohio Item Number: OH160007 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

ENS 51980 +/-
Where
Akron General Medical Center Akron, Ohio (NRC Region 3)
License number:	02120780000
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+923.57 h38.482 days <br />5.497 weeks <br />1.265 months <br />)
Opened:	Stephen James 15:34 Jun 3, 2016
NRC Officer:	Dong Park
Last Updated:	Jun 3, 2016
51980 - NRC Website
v • d • e

v t e Emergency Notification System
Akron General Medical Center with Agreement State
WEEKMONTHYEAR2017-11-06T05:00:00 [Table view]
[ENS list for Akron General Medical Center]

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