AGREEMENT STATE REPORT - LOSS OF IODINE-125 SEED
The following was received from the state of Georgia via email:
"An Iodine-125 seed [assayed at 69 microCuries on March 24, 2020 (Best Model 10172-11, Double wall titanium encapsulated, Serial Number: 49802A20)] used for breast lesion localization was shipped within a tissue specimen from Piedmont Fayette Hospital to Piedmont Atlanta and then lost into the ordinary solid waste stream, rather than being recovered and placed in decay-in-storage at Piedmont Fayette, as is the standard procedure.
"The seed was implanted in a patient with a breast lesion at Piedmont Fayette on March 24, 2020. The lesion containing the seed was successfully removed in surgery and sent to the pathology lab on March 30, 2020. The presence of the seed in the specimen was verified in pathology by Neoprobe measurement. There was no pathology physician assistant present that day and the pathologist was not notified. A lab staff member arranged for all specimens to be shipped to Piedmont Atlanta. The specimens, including the one containing the seed, were shipped by MedSpeed courier service that same day. At the Atlanta campus, the specimen with the seed was processed by the normal procedure on April 1, 2020. The histotechnologist there removed what he thought was a marker or a clip and discarded it in the regular waste bin. The waste containing the seed was removed from the Atlanta campus [in a bag of solid waste] and transported to the [Pine Ridge Regional Landfill] by the waste disposal company's normal procedure on or around April 2, 2020.
"[The Radiation Safety Officer (RSO)] was notified by phone on April 3, 2020 and searches of all relevant areas at Piedmont Atlanta were performed by staff using a GM survey meter with pancake probe as well as with a Sodium Iodide scintillator probe that day. No evidence of radiation or the seed was found in any location.
"The proper course of action that should have been taken in order to prevent this situation is as follows: The pathologist at Fayette should have been notified that there was a specimen with a radioactive seed. The pathologist would have removed the seed and the pathology staff would have contacted Nuclear Medicine to retrieve the seed and place it in decay-in-storage. Seeds should not leave the Fayette Campus.
"In [the RSO's] estimation, it is unlikely that any occupationally exposed worker or member of the public received any significant exposure or exceeded any dose limit.
"All staff in pathology have been educated on the circumstances that led to this incident. The procedure has been updated to clarify what actions should be taken if a specimen with a seed arrives in pathology when no pathology physician assistant is present. Knowledge of this procedure has been added to the competency checklist for pathology employees."
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 |