Event Notification Report for July 12, 2013
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/11/2013 - 07/12/2013
EVENT NUMBERS
49401
Agreement State
Event Number: 49401
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: ROSWELL PARK CANCER INSTITUTE
Region: 1
City: BUFFALO State: NY
County:
License #: NYS #2923
Agreement: Y
Docket:
NRC Notified By: ROBERT SNYDER
HQ OPS Officer: JOHN SHOEMAKER
Licensee: ROSWELL PARK CANCER INSTITUTE
Region: 1
City: BUFFALO State: NY
County:
License #: NYS #2923
Agreement: Y
Docket:
NRC Notified By: ROBERT SNYDER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/02/2013
Notification Time: 09:52 [ET]
Event Date: 07/12/2013
Event Time: 00:00 [EDT]
Last Update Date: 10/02/2013
Notification Time: 09:52 [ET]
Event Date: 07/12/2013
Event Time: 00:00 [EDT]
Last Update Date: 10/02/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JUDY JOUSTRA (R1DO)
FSME EVENTS RESOURCE (EMAI)
JUDY JOUSTRA (R1DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - LOST IODINE 125 SEALED SOURCE SEED
The following information was received from the New York State Department of Health (NYS DOH) via facsimile:
"The source was a seed source for Breast Localization Procedures. The medical procedure occurred on July 12, 2013. A tissue specimen was removed from a patient. The localization seed was identified and removed from the specimen post-surgery. The seed was not returned to the Nuclear Medicine Department per institute policy, which initiated a facility search for the missing RAM [radioactive material]. Immediate actions included conducting extensive facility area surveys for several weeks. The source was declared officially lost on August 29, 2013. The root cause involved a failure to follow the facility policy. The seed was allowed to become lost, after it had been properly identified. Corrective actions involve an incident review with the pertinent staff and an in-service refresher training for all staff. The facility has been informed by NYS DOH that this event should have been reported immediately on July 12, 2013."
Manufacturer, Best Medical International, Inc., Model No. 2301 I-125, Activity, 140 microCuries.
New York State Report ID No. NY-13-05
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
The following information was received from the New York State Department of Health (NYS DOH) via facsimile:
"The source was a seed source for Breast Localization Procedures. The medical procedure occurred on July 12, 2013. A tissue specimen was removed from a patient. The localization seed was identified and removed from the specimen post-surgery. The seed was not returned to the Nuclear Medicine Department per institute policy, which initiated a facility search for the missing RAM [radioactive material]. Immediate actions included conducting extensive facility area surveys for several weeks. The source was declared officially lost on August 29, 2013. The root cause involved a failure to follow the facility policy. The seed was allowed to become lost, after it had been properly identified. Corrective actions involve an incident review with the pertinent staff and an in-service refresher training for all staff. The facility has been informed by NYS DOH that this event should have been reported immediately on July 12, 2013."
Manufacturer, Best Medical International, Inc., Model No. 2301 I-125, Activity, 140 microCuries.
New York State Report ID No. NY-13-05
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