ML20216J937
| ML20216J937 | |
| Person / Time | |
|---|---|
| Issue date: | 09/15/1978 |
| From: | Higginbotham L, Metzger J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE) |
| To: | |
| References | |
| PNO-78-164, NUDOCS 9804220039 | |
| Download: ML20216J937 (2) | |
Text
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PRELIMINARY NOTIFICATION
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September 15, 1978 PRELTMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE--PHO-78-164 This reliminary notification constitutes EARLY notice of an event of P6ST18LE safety or public interest significance.
The information i
presented is as initially received without verification or evaluation and is basically all that is known by IE staff on this date.
F_acility: Veterans Administration Hospital Los Angeles, California License No. 04-00818-04
Subject:
LOST IRIDIUM-192 SEEDS At 9:00 a.m. on the morning of September 13, a resident physician performing a source count, discovered that three (3) nylon ribbon iridium-192 sources (seeds), each containing 7.5 millicuries had been lost from the implantation site in the jaw of a therapy patient.
The sources were ejected sometime during the 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> period beginning at 9:00 a.m., September 12, when the same resident had performed the last
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previous source count.
One of the source ribbons was recovered promptly from the patient's bed
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and reimplanted. The other two source ribbons were apparently removed from the patient's room with the laundry or trash.
The licensee's search of the hospital premises, trash and sewer lines resulted in the recovery of one of the ribbon sources from the hospital laundry.
All areas of the laundry were surveyed unsuccessfully for the second missing source.
Trash from the hospital is compacted, removed and disposed at a sanitary land fill disposal site by a commercial con-tractor.
The compacted trash was surveyed on September 13 prior to its removal from the hospital grounds.
The results of the survey were negative.
The licensee is continuing efforts to locate the missing source.
The licensee stated that there is nothing to indicate that any individual received a significant exposure as a result of the loss of control of the three sources. The dose rate from 7.5 millicuries of iridium-192 at one meter is approximately 3.6 milliroentgens per hour.
The licensee is preparing a report of the occurrence in accordance with the requirements of 10 CFR 20.402, Reports of Theft or Loss of Licensed Material.
There has been no media interest and the licensee has not and does not pres-ently plan to issue a press release.
CONTINUED g42g39780915
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PNO-78-164 PDR
s Page 2 September 15, 1978 i
Continued PN0-78-164 l
This Preliminary Notification is issued for information only and ne further action by IE is anticipated.
Region V received notification of this occurrence by telephone from the licensee's radiation protection officer at 3:30 p.m. on September 13, 1978.
Contact:
JRMetzger, IE x28188 LBHigginbotham, IE x28098
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Distribution:
Transmitted H St /11 Ybk Chairman Hendrie Commissioner Bradford S. J. Chilk, SECY Commissioner Kennedy Commissioner Ahearne C. C. Kammerer, CA Commissioner Gilinsky (ForDistribution)
Transmi tted: MNBB / L', B P Bldg J.1',[t/
J. G. Davis, IE L. V. Gossick, EDO H. R. Denton, NRR Region M // 6'[
S. H. Hanauer, EDO J. J. Fouchard, PA SS Bldg h* $~7 (MAIL)
N. M. Haller, MPA C. V. Sm'ith, NMSS
H. K. Shapar, ELD PRELIMINARY NOTIFICATION i
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