Event Notification Report for June 22, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/21/2022 - 06/22/2022
EVENT NUMBERS
55994
55994
Non-Agreement State
Event Number: 55994
Rep Org: West Virginia University
Licensee: West Virginia University
Region: 1
City: Morgantown State: WV
County:
License #: 47-23066-02
Agreement: N
Docket:
NRC Notified By: Stephen Root
HQ OPS Officer: Lloyd Desotell
Licensee: West Virginia University
Region: 1
City: Morgantown State: WV
County:
License #: 47-23066-02
Agreement: N
Docket:
NRC Notified By: Stephen Root
HQ OPS Officer: Lloyd Desotell
Notification Date: 07/15/2022
Notification Time: 14:00 [ET]
Event Date: 06/22/2022
Event Time: 00:00 [EDT]
Last Update Date: 09/08/2022
Notification Time: 14:00 [ET]
Event Date: 06/22/2022
Event Time: 00:00 [EDT]
Last Update Date: 09/08/2022
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
Person (Organization):
Bickett, Brice (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Bickett, Brice (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
MISSING I-125 SEED
The following information was provided by the licensee via email:
"On June 22, 2022, West Virginia University Radiation Safety Department discovered that one Iodine-125 seed (Isoaid Model IAl-125A, titanium capsule sealed source, seed lot number 202280796) used in a Radioactive Seed Localization procedure was missing. The seed, with an activity of 268 microCi, was implanted into a lesion in the patient's right breast on June 16, 2022. A second seed, with the same activity, was implanted into the same lesion in the patient's right breast on the same day. A third seed, with the same activity, was implanted into a lesion in the patient's left breast on the same day. The surgery to remove the lesions was completed on the same day. On June 21, 2022, a Radiation Safety specialist picked up 2 seeds from the patient in question along with 7 seeds from different patients. At this time the Radiation Safety specialist did not have seed implantation records for all the seeds retrieved as they were not available at the Breast Care Center. On June 22, 2022, the specialist retrieved the seed implantation records and noted that the patient in question had a total of three seeds implanted and reported the seed as missing to the Radiation Safety Department Manager. An investigation determined that the seed arrived in the Pathology Gross Room but was likely inadvertently discarded in the trash or flushed down the sink."
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 provided by the licensee via email:
"On June 22, 2022, West Virginia University Radiation Safety Department discovered that one Iodine-125 seed (Isoaid Model IAl-125A, titanium capsule sealed source, seed lot number 202280796) used in a Radioactive Seed Localization procedure was missing. The seed, with an activity of 268 microCi, was implanted into a lesion in the patient's right breast on June 16, 2022. A second seed, with the same activity, was implanted into the same lesion in the patient's right breast on the same day. A third seed, with the same activity, was implanted into a lesion in the patient's left breast on the same day. The surgery to remove the lesions was completed on the same day. On June 21, 2022, a Radiation Safety specialist picked up 2 seeds from the patient in question along with 7 seeds from different patients. At this time the Radiation Safety specialist did not have seed implantation records for all the seeds retrieved as they were not available at the Breast Care Center. On June 22, 2022, the specialist retrieved the seed implantation records and noted that the patient in question had a total of three seeds implanted and reported the seed as missing to the Radiation Safety Department Manager. An investigation determined that the seed arrived in the Pathology Gross Room but was likely inadvertently discarded in the trash or flushed down the sink."
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