CBRN event in New York, Buffalo area, United States of America on Tue 4th November 2014

October 9, 2014 the Pathology Department at Roswell Park Cancer Institute “misplaced” a I125 seed radioactive source, which is used for localization in breast surgery. The loss occurred when the two breast localization seeds were removed from the patient, but not “extracted from the specimen,” which, according to written documentation, had been sent to the pathology department against Institute Policy; the seeds should had been sent back to Nuclear Medicine. Following a comprehensive search of the Pathology, Nuclear Medicine and Environmental Services areas, one of the seeds was found in trash already discarded by the Pathology Department. Weeks of further searches through the Institute’s regulated medical waste, including radioactive waste, yielded no finding of the second seed. On November 4th, 2014, the seed was officially declared lost. Following a review of the incident, a “training oversight” was identified, which has been remedied through Department Fellow training.