Event Notification Report for June 25, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/24/2020 - 06/25/2020
EVENT NUMBERS
54836
Agreement State
Event Number: 54836
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: Roswell Park Cancer Institute Corp.
Region: 1
City: Buffalo State: NY
County:
License #: 2923
Agreement: Y
Docket:
NRC Notified By: Daniel J. Samson
HQ OPS Officer: Brian P. Smith
Licensee: Roswell Park Cancer Institute Corp.
Region: 1
City: Buffalo State: NY
County:
License #: 2923
Agreement: Y
Docket:
NRC Notified By: Daniel J. Samson
HQ OPS Officer: Brian P. Smith
Notification Date: 08/13/2020
Notification Time: 16:36 [ET]
Event Date: 06/25/2020
Event Time: 00:00 [EDT]
Last Update Date: 08/13/2020
Notification Time: 16:36 [ET]
Event Date: 06/25/2020
Event Time: 00:00 [EDT]
Last Update Date: 08/13/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
- CNSC (CANADA) (FAX)
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
- CNSC (CANADA) (FAX)
AGREEMENT STATE REORT - MISSING I-125 SEED
The following was received via fax from the New York State Department of Health:
"On July 7, 2020, the [New York State] Department [of Health] was notified of a missing Iodine-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 142 microCuries) at Roswell Park Cancer Institute in Buffalo, New York. An lodine-125 localization seed was removed from a patient in a procedure that took place on June 25, 2020, and is believed to have been lost in the intraoperative frozen section room in surgery. The RSO [Radiation Safety Officer] was informed of the missing seed on June 29, 2020. The facility conducted searches and surveys of the Surgery, Pathology, Radiation Safety and Environmental Services areas. Trash and regulated medical waste were also surveyed and inspected. It is believed that the seed will be recovered from the facility's regular trash, but more likely in the facility's radioactive waste."
New York State Event Report Number: NYDOH 20-02
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 was received via fax from the New York State Department of Health:
"On July 7, 2020, the [New York State] Department [of Health] was notified of a missing Iodine-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 142 microCuries) at Roswell Park Cancer Institute in Buffalo, New York. An lodine-125 localization seed was removed from a patient in a procedure that took place on June 25, 2020, and is believed to have been lost in the intraoperative frozen section room in surgery. The RSO [Radiation Safety Officer] was informed of the missing seed on June 29, 2020. The facility conducted searches and surveys of the Surgery, Pathology, Radiation Safety and Environmental Services areas. Trash and regulated medical waste were also surveyed and inspected. It is believed that the seed will be recovered from the facility's regular trash, but more likely in the facility's radioactive waste."
New York State Event Report Number: NYDOH 20-02
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