Semantic search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 56969 | 5 February 2024 14:00:00 | Agreement State | Lost Source | The following information was provided by the New York State Department of Health (the Department) via fax: The radiation safety officer for Cardinal Health (New York State (NYS) Radioactive Materials License (RAML) C3046) noted a missing vial of ln-111 oxyquinoline (oxine) on the morning of 02/05/24. The Administrative Director phoned NYS Department of Health (DOH) on 02/06/24 at 1500 EST, to report the missing vial. The vial contained approximately 1 millicurie of ln-111 at the time of transfer. The sealed vial was shipped from the Cardinal Health facility, RAML C2593, in Bronx, NY, by company courier, received at (the Plainview facility), RAML C3046, and subsequently lost. This shipment was a transfer between Cardinal Health facilities and not to the end user for clinical administration. To date, Cardinal Health has not located the vial, but is actively attempting to locate its whereabouts and investigate the root cause. Based on information at this time, external radiation levels outside of the shipping container would not likely pose any concern or adverse health risks to members of the public, including couriers. As of the date and time of this notification, the expected activity of the vial is estimated to be 0.56 millicuries and will rapidly decay to background levels provided the short half-life of ln-111 (2.8 days). In accordance with 10 CFR 20.2201(a)(ii), the activity of ln-111 was approximately 10 times the quantity specified in Appendix C to 10 CFR 20, which prompts a 30-day telephone report and subsequent written report within 30 days of the initial notification to the Department. It is possible that due to the short half-life, this vial may in actuality contain less than the reportable quantity prescribed by 10 CFR 20.2201(a), however, this event is being reported out of an abundance of caution as the circumstances around this lost vial are not immediately available. NYSDOH is actively monitoring this incident and has assigned incident number 1474 to track this event. Cardinal Health is currently working through the initial investigation of this event, and anticipates submitting a thorough outline of their investigation, primary and contributing causes, and steps to prevent recurrence as prescribed in addition to all items prescribed by 10 CFR 20.2201(b), under NYS (10 NYCRR 16.15) requirements. New York State Event Report Number: NY-24-01 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 | ||
| ENS 56627 | 10 July 2023 04:00:00 | Agreement State | Eluate Exceeded Mo-99 Limit | The following information was provided by the Ohio Department of Health (ODH) via email: Cardinal Health made a telephone notification (to ODH) on 7/17/2023 that a Lantheus Tc-99m generator, lot number M190311A, exceeded the Mo-99 breakthrough limits. The generator was eluted three times on 7/10/23. The results of the Mo-99 breakthrough test were 0.224, 0.313, and 1.705 microcuries Mo-99/millicurie Tc-99m. None of these elutions were used to dispense activity to customers or prepare drug kits. No doses containing Tc-99m from this generator were administered to patients. Lantheus was notified on 7/10/23, the generator was pulled, and a return kit was provided. Ohio Incident Number: OH230008 | ||
| ENS 55881 | 5 May 2022 14:45:00 | Agreement State | Transportation Event | The following was received from the State of Kansas Department of Health and Environment via email: At approximately 0945 CDT on May 5, 2022, the Kansas Department of Health and Environment (KDHE) was notified of a Cardinal Health carrier involved in an incident where the vehicle was swept off the road due to flooding. The nearest intersection to the site of the incident is E 520th Ave and S 240th Ave in Pittsburgh, KS, near the Missouri border. The vehicle was transporting unit doses of Tc-99m (total activity unknown at this time) from its Springfield, Missouri facility to locations in Kansas. The vehicle (type unknown at this time) is currently sitting in approximately 3 to 3.5 feet of water. KDHE was informed that the driver had to exit the vehicle through the window, which remains open. KDHE was informed that the driver left the area and the vehicle is currently unattended. The weather forecast includes additional rain and potential flooding for the rest of the day into the evening and a towing company is unable to assist until the water recedes. It is unknown at this time when the vehicle will be able to be retrieved. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: Container information: Syringes containing Tc-99m individually contained in pigs Pigs contained in nylon bag No placarding of vehicle Containers labeled with RADIOACTIVE WHITE-I (less than 0.5 mrem/hr on surface) Vehicle also likely contained empty used Tc-99m syringes Notified: DHS, FEMA, USDA, HHS, DOE, CISA, EPA, DOT, KS All Hazard Notification System Notified via email: FDA, DHS, FEMA National Watch Center, FEMA NRCC SASC,CWMD Watch Desk
The following information was received via email from the State of Kansas: The Cardinal Health RSO was able to access the vehicle on Friday (5/6/2022) afternoon and removed the radioactive material which was then returned to the pharmacy. The RSO also performed surveys and wipes and found them to be below action levels. The contents of the vehicle was confirmed as follows: "There were two containers of doses containing a total of 121 doses and about 200 mCi of Tc-99m, calibrated for between 0700 and 1300 CDT on Thursday (5/5/2022). Notified R3DO (Skokowski), R3DO (Stoedter), R4DO (Gaddy), IR (Kennedy), NMSS Events Notification email group. | ||
| ENS 54357 | 29 October 2019 08:15:00 | Agreement State | Agreement State Report - Stolen Sources | The following information was received via email: Licensee called (the Mississippi Division of Radiological Health) to report a carjacking of one of its drivers carrying two packages of PET doses. The carjacking occurred at approximately 0315 CDT at a gas station in Jackson, MS. The local law enforcement was notified. The vehicle has still not been recovered. Stolen sources were F-18. Source 1 had an activity of 6000.627 mCi at 0149 CDT and source 2 had an activity of 1694.932 mCi at 0151 CDT. Incident Report No.: MS-190004 THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 54225 | 14 August 2019 17:00:00 | Agreement State | Agreement State Report - Vehicle Accident During Radiopharmaceutical Transport | The following was received from the State of Maryland via email: On August 14, 2019, at 1415 EDT, the Maryland Department of the Environment (MDE) Hazardous Materials Division contacted the MDE Radiological Health Program (RHP) concerning a vehicular accident in the south bound lane of State Route 4 near the intersection of Dower House Road, east of Forestville, MD. A Prince George's County HazMat responder contacted MDE/RHP at 1430 EDT to provide details of the accident. The initial transportation accident, as logged in at 1300 EDT, indicated the transport vehicle from Cardinal Health (MD-33-198-01) was transporting two cases of radiopharmaceuticals to two medical facilities in southern Maryland for its 'third run.' A tractor trailer collided with the rear of the transport vehicle at a controlled intersection just after the traffic light turned green. One case contained 3 lead pigs containing Tc-99m totaling 395.67 mCi. The second case contained 2 lead pigs containing Tc-99m totaling 106.90 mCi. The cases were originally marked as White 1, with a Transportation Index of 0. The cases remained fully blocked and braced following the accident. The containers were not compromised. Two senior pharmacist employees from Cardinal Health responded to the scene and took possession of the containers after carefully surveying the cases. The cases went on to be delivered to the intended destination. The Cardinal Health office in Dublin, OH called the National Response Center at 1627 (Incident Number 1255161) to report this accident. MDE was contacted at 1645. MDE will further investigate this incident. | ||
| ENS 53931 | 26 February 2019 04:00:00 | Agreement State | Agreement State Report - Mo-99/Tc-99 Breakthrough Limit Exceeded. | The following report was received via e-mail: On March 7, 2019, the Ohio Department of Health received a phone notification from Cardinal Health stating the first elution on 2/26/2019 from the NorthStar RadioGenix Mo-99/Tc-99m generator exceeded breakthrough limits in Ohio Administrative Code 3701:1-58-35 (10 CFR 35.204). The measured breakthrough was 0.252 microCuries Mo-99 per milliCurie Tc-99m. Cardinal Health stated this was an isolated event and all other elutions have been within the limits. The licensee is using the elution for research only; it is not for human use. Cardinal Health has contacted the manufacture to determine the cause. Ohio Event: 190004 | ||
| ENS 53359 | 23 April 2018 04:00:00 | Agreement State | Agreement State Report - Stolen Technicium-99 | The following is a synopsis of information received via E-mail: St. Vincent Medical Center in Fernandina Beach, Florida (License Number: 0014-8) received five (5) doses of Technicium-99 on the morning of April 16, 2018 from Cardinal Health in Jacksonville, Florida. Portions of the dose were used on patients. Later that day, the remainder of the unused doses were placed in a 'lock box' which was located outside the building. The doses were to be picked up and returned to Cardinal Health. This morning, April 23, 2018, the driver from Cardinal Health went to retrieve the doses and found the lock box had been broken into and the Tc-99 doses had been removed. The Fernandina Police were notified (report #2018-00007035). The activity of the Tc-99 is estimated to be 30 to 40 mCi. Florida Incident Number: FL18-053 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 | ||
| ENS 52659 | 22 March 2017 04:00:00 | Agreement State | Agreement State Report - Package Lost During Shipment | The following information was provided by the State of Ohio via email: On 3/31/17 the licensee (Cardinal Health) notified ODH (Ohio Department of Health) that a package containing a Ge (Germanium) Generator was being returned to the manufacturer (IRE Elit) in Belgium. The package was sent on 3/7/17 and on 3/22/17 Cardinal was notified by IRE that the package had not arrived. Cardinal immediately contacted the shipper (common carrier) concerning the package and at that time they had indication that it was stuck in customs in Paris, France. On 3/31/17 Cardinal was told by (common carrier) that the package has not been located in customs and they are continually searching for the package. On 4/3/17 licensee told by (common carrier) that there was no record that the package had ever left the (common carrier) hub in . . . and still have not located the package. Package is labeled as a Yellow II DOT Type A container with 1371 MBq (37 mCi) of Germanium 68. Solid/self-shielded container with a TI at shipment of 0.3. Item No.: OH170002 Reference Number: OH 2017-017
The following information was received from the State of Ohio via email: Package was located by common carrier and returned to the licensee (Cardinal Health) in Dublin, Ohio. Package had one of two security seals still intact; however, licensee stated that there was no indication that package had been opened during time in transit. Package will be wipe tested and repacked for return to manufacturer. Notified the R1DO (Jackson), R3DO (Jeffers) and NMSS Events via email. 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 | ||
| ENS 52617 | 17 March 2017 11:00:00 | Agreement State | Agreement State Report - Transportation Accident Damaging Licensed Material | The following report was received via email: At about 0700 (EDT) on March 17, 2017, the Department (Pennsylvania Bureau of Radiation Protection) received notification through the Pennsylvania Emergency Management Agency of a vehicle fire near mile marker 286 on I-76 (PA Turnpike) (near Reading, PA). The vehicle was carrying approximately 0.6 Ci (22 GBq) Tc-99m and 1 Ci (37 GBq) of F-18 for Cardinal Health (PA licensee PA-0415). Department emergency response and radiological health physics staff responded to the scene. The vehicle was entirely engulfed in flames and allowed to burn itself out. There are no reports of injuries. A representative from the licensee was on scene and collected contaminated debris and ash which was returned to their facility for decay. The vehicle will be removed from the scene and isolated to allow any remaining material to decay. Departmental health physics inspector will oversee operations. PA Event Report ID No: PA 170006 | ||
| ENS 51971 | 1 June 2016 05:00:00 | Agreement State | Agreement State Report - Two Radioactive Materials Packages Not Located After Carrier Accident | The following report was received from the Texas Department of State Health Services via facsimile: On June 1, 2016, the licensee notified the Agency (Texas Department of State Health Services) that one of its shipments was involved in a transportation accident. A carrier was transporting two type A packages, each containing a vial of fluorodeoxyglucose (F-18), 10 mCi, when it was involved in an accident on an unreported freeway. Emergency responders arrived at the scene, the driver was taken to a hospital. The vehicle was cleared from the roadway. It is uncertain at this time where the vehicle or the packages are located. The licensee is obtaining information to recover the radioactive materials. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I 9408
The following report was received from the Texas Department of State Health Services via email: Agency (Texas Department of State Health Services) received call 1529 CDT from licensee. He informed us (Texas) that the packages were intact, not damaged, and recovered from the accident vehicle. The packages are currently located at the original pharmacy location in Dallas. The vial activity amount was 15 mCi each instead of the reported 10 mCi. The licensee stated that since the driver was not his employee he could not obtain information on the driver. The packages were intact and no exposures occurred. Notified the R4DO (Deese), NMSS Events, and Mexico (via email).
The following report was received from the Texas Department of State Health Services via email: On June 23, 2016, the licensee provided updated information to the Agency (Texas Department of Health Services). This information stated the activity of the radionuclide was 62 and 56 millicuries instead of the 15 millicuries previously reported. Notified the R4DO (Hipschman), NMSS Events Resource (via e-mail) and Mexico (via e-mail). 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 | ||
| ENS 50920 | 1 March 2015 04:00:00 | Agreement State | Agreement State Report - Radiation Technician Potential Overexposure | The following information was obtained from the State of Florida via email: An employee of Cardinal Health had a dosimeter reading of 140 REM. The employee routinely wears one whole-body badge and two ring dosimeters assigned to him. These findings are for the wear period of 2/16/2015-3/1/2015. The whole body badge had a reported dose of 140884 mRem DDE and 241488 mRem SDE. (Cardinal Health) stated that the individual didn't have any reportable readings from their rings badges for this wear period. The individual is showing no symptoms of overexposure and has been removed from handling radioactive material as a safety precaution. It is believed that the badge may have become contaminated therefore distorting the correct exposure reading. Cardinal Health is reportedly conducting an investigation to find the cause and extent of this incident. Pending the Landauer report and some additional information, an investigator will be assigned to inspect their laboratory for safety and confirm Cardinal Health's investigative conclusions. Florida Incident Number: FL15-023 | ||
| ENS 50481 | 27 August 2014 07:00:00 | Agreement State | Agreement State Report - Radioactive Material Release Exceeding Emission Limit | The following report was received from the State of Washington via email: Event Narrative: Notification (was given) to (Washington) State by the licensee for exceeding the allowable total abated emission limit for this unit (Cardinal Health 414, LLC). The limit is 7.4 mRem to the MEI (Maximally Exposed Individual) while the licensee acknowledges a release so far in 2014 of a total of 23.7 mRem (21.5 from Fluorine 18 and 2.2 from Carbon 11). The licensee believes the problem is a combination of errors including both human and engineering. Proposed corrective actions include changes in procedures as well as changes in the air discharge system components. NMED Report Number: WA-14-039. | ||
| ENS 49675 | 6 December 2013 05:00:00 | Agreement State | Agreement State Report - Licensed Material Recovered at a Landfill | NOTIFICATIONS: On December 6, 2013 the PA Department of Environmental Protection (PA DEP) was notified of a radiation alarm at Modern Landfill in York, PA. A health physics consultant for the landfill had responded and determined that two bare molybdenum-99 (Mo-99) generator cores were the cause of the alarm. The Mo-99 generators had their labels intact and noted an activity of 18 curies (Ci) on 10/29/2013 and 11/06/2013. Expiration dates were 11/12/2013 and 11/19/2013 respectively. Per 10 CFR 20.2201, decay correcting the activity would prompt a 30-day report per 10 CFR 22.2201(a)(ii); however, after further investigation and discussion with the licensee, a conservative (immediate) report per 10CFR 20.2201(a)(i) may be required. EVENT DESCRIPTION: The December 6th initial notification to the PA DEP/BRP was due to a load of solid waste possibly containing Mo-99, versus Tc-99m which is often found to set off landfill radiation alarms. Upon off-loading the waste and discovery of two bare Mo-99 generator cores and investigation the following week, the serial number on each of the Mo-99 generator labels revealed they were from a Pennsylvania nuclear pharmacy licensee, Cardinal Health (C. H.), PA-0385. A reactive inspection was initiated. The RSO for C.H. concluded that the generators may have been stolen after their expiration date, and thus would involve a decayed activity of 510 mCi. This is greater than 1,000 times the quantity specified in 10 CFR 20 Appendix C for Mo-99 (that is, greater than 100 mCi). PA DEP/BRP is expecting the licensee to assess the range of whole body and extremity doses to the individual(s) that disassembled these Mo-99 generators using conservative bounding assumptions. No one has admitted to the removal of the Mo-99 from the C.H. facility. CAUSE OF THE EVENT: Possible theft as a crime of opportunity for scrap lead shielding. ACTIONS: A reactive inspection by the PA DEP Regional Office has already occurred and further evaluation of the potential individual radiation exposure and needed corrective actions are ongoing. PA Event Report ID No: PA130029 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 | ||
| ENS 49402 | 23 September 2013 04:00:00 | Agreement State | Agreement State Report - Radiopharmaceutical Worker Received >50 Rem to Both Hands | The following information was received from the State of Georgia via email: An authorized user exceeded the annual extremity limit for both the left and right finger. Landauer sent an immediate report (report date 9/23/2013) to the corporate office of Cardinal informing them of the over exposure. At the current moment, Cardinal does not know the time frame at which this took place, but should know in a week and a half when Landauer will send their monthly report. The immediate report issued by Landauer reported the following doses: Employee One, who resigned on August 13, 2013, received 57,554 mrem for the left finger and 52,681 mrem for their right finger. Employee Two received 22,016 mrem - left finger and 39,861 mrem - right finger. Employee Three received 43,140 mrem - left finger and 16,647 mrem - right finger. Cardinal will be investigating the incident to determine the root cause. They will be looking a systemic issues at the facility. Georgia Incident Number: 72258 | ||
| ENS 47560 | 21 December 2011 08:00:00 | Agreement State | Agreement State Report - Iodine-125 Brachytherapy Seed Missing from Transportation Package | The following report was received by telephone from the State of Nevada. A representative of the State of Nevada Radiation Control Program was notified by a call from Cardinal Health and Summerlin Hospital in Las Vegas NV concerning a missing I-125 brachytherapy seed. Summerlin Hospital on or about 12/21/11 transferred 33 Iodine-125 brachytherapy seeds to Cardinal Health for shipment back to Bard Brachytherapy in Illinois. The 33 Iodine-125 seed shipment was packaged and sent by Cardinal Health to Bard via commercial carrier on or about 12/21/11. Upon receipt of the seeds by Bard, the top of the shipping pig was discovered to not be completely sealed. Some of the seeds were outside the pig but within the shipping package. After all the seeds were inventoried, a total of 32 seeds were received by Bard. At this time, one of the seeds appears to be unaccounted for. The missing I-125 seed had an activity of 0.23 milliCuries at the time of shipment. The half-life of Iodine-125 is approximately 60 days. Bard has surveyed the local carrier that transported the shipment to its facility. It has also surveyed the regional facility of the shipping carrier. Cardinal Health and Summerlin are still attempting to confirm the original inventory of seeds was 33. The State of Nevada is continuing its investigation of the missing seed. 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 | ||
| ENS 46566 | 28 December 2010 06:00:00 | Agreement State | Agreement State Report - Transportation Accident Involving Radiopharmaceuticals | The following information was received by email: DRH (Mississippi State Department of Health) was notified at 0720 (CST), about a transportation accident in Jackson, MS, on Riverside Drive. Cardinal Health Nuclear Pharmacy Services was delivering radiopharmaceuticals to Baptist Hospital and Kings Daughters Hospital. The driver hit an icy patch on the road where a water main had broken. The driver lost control of the delivery vehicle. The vehicle turned over in the median and the driver was trapped. DRH responded at 0730 (CST). The driver was not injured. Packages were dislodged from their protective security rack, that is required to prevent shifting and movement of packages. Radiopharmaceutical packages were surveyed and wiped for contamination. (No contamination was detected.) The packages were picked up by the Radiation Safety Officer so they could be delivered to the hospitals. The pharmacy's vehicle was then released to the wrecker service. DRH closed this case on 12/28/2010. MS Report No.: MS-10010. | ||
| ENS 46451 | 2 December 2010 11:20:00 | Agreement State | Agreement State Report - Employee Contaminations During Cyclotron Operation | The following information was received by e-mail: The state reported that three employees of Cardinal Health were contaminated by Fluorine 18 (F-18) from operation of a cyclotron. Initial contamination of the employees was 1600 cpm. Soap and water was used to decontaminate the personnel and at 1130 PST the contamination was reported to be 1300 dpm. The licensee believes the cause of the contamination to be faulty delivery lines. The cyclotron device is a General Electric Accelerator PETrace. Nevada Incident Number: NV100022
The following information was received by email from the State of Nevada: The State of Nevada is retracting the Event Report sent on December 2, 2010, regarding Cardinal Health. This event does not need to be reported based on the fact that a contamination events must restrict access to the area for more than 24 hours or cause doses to workers that exceed regulatory limits in order to be reportable. Due to the short half life of the material involved and the fact that it was limited to the transfer tube, it is unlikely that anyone received a dose >1 ALI (24 hr notification) or >5 ALI (immediate notification). Notified R4DO (Powers) and FSME (McIntosh). | ||
| ENS 45342 | 11 September 2009 09:30:00 | Agreement State | Agreement State Report - Contaminated Pharmacy Shipment Package | '(A) contaminated package (was) received at Mission Hospital from Cardinal Health - Asheville. The RSO (Radiation Safety Officer) of Mission Hospital received a shipment of Tc-99 unit doses from Cardinal Health pharmacy. The exterior of the box was contaminated to (approximately) 180,000 dpm/100 (square centimeters). Upon determination of the contamination, Mission Hospital contacted Cardinal Health pharmacy and they came and picked up the box. Mission Hospital did not open the box. After the box was picked up, a small spot of contamination was found on the absorbent paper that the box had been placed on. Mission Hospital removed the paper, which removed the contamination, and placed it as waste into their decay-in-storage area. This level exceeds the reportability limit of 22,000 dpm/100 (square centimeters) of 15A NCAC (North Carolina Administrative Code) 11.1627; which references 10 CFR 71.87; which references 49 CFR 173.443. 15A NCAC 11.1627(d) requires an immediate notification to the (North Carolina Radiation Protection Section) Agency. North Carolina Incident 09-43. | ||
| ENS 45363 | 21 July 2009 04:00:00 | Agreement State | Agreement State - Potential Extremity Overexposure | A licensee radio-pharmacist was preparing Flourine-18 (F-18) doses for use, when a manipulator malfunction occurred. The radio-pharmacist continued to prepare the F-18 manually instead of securing the process. This led to a potential dose to the radio-pharmacist's right hand of greater than 50 rem. This dose is a rough estimate from whole body dose values and reconstruction of the event due to the fact the radio-pharmacist was not wearing any dosimetry on the extremity. The State will continue to investigate this event and provide additional information as it become available. | ||
| ENS 44307 | 13 June 2008 08:00:00 | Agreement State | Agreement State Report Involving a Vehicle Transporting Radioactive Material | On 6/13/08, a Cardinal Health vehicle transporting Tc-99m and I-131 was involved in a vehicle accident on Route 495N. The vehicle overturned spilling eleven (11) shipping containers onto the roadway. The containers were not damaged and no radioactive material was released on the roadway or to the surrounding environment. The rad material was returned to the Cardinal Health facility in Woburn, MA. The licensee notified the National Response Center and the Commonwealth of Massachusetts.
The following is submitted as additional information for NMED Item No. 080358 (EN44307): The licensee, Cardinal Health Nuclear Pharmacy, provided the Massachusetts Radiation Control Program with corrective actions they have taken to preclude a recurrence of this event. The corrective actions include retraining all delivery personnel (performed on June 18, 2008) on the importance of remaining alert while transporting radioactive materials. Delivery personnel were instructed not to work longer hours prior to the start of their delivery route. Notified R1DO (Caruso) | ||
| ENS 44264 | 3 June 2008 05:00:00 | Agreement State | Agreement State Report - Radiopharmaceuticals Delivery Vehicle Accident | The State provided the following information via facsimile: On June 3, 2008, a Cardinal Health delivery vehicle carrying nuclear medicine doses was involved in a vehicle accident. Some of the ammo boxes containing the syringe pigs opened, however the syringe pigs remained intact. No radioactive material was spilled or leaked during this accident. Louisiana Report: LA0800012 | ||
| ENS 44136 | 9 April 2008 12:00:00 | Agreement State | Agreement State - Mississippi - Traffic Accident Involving Truck Carrying Tc-99M | The State provided the following information via email: DRH (Mississippi Division of Radiological Health) received a phone call from Cardinal Health RSO on 4-9-08 about a transportation accident involving one of their transport vehicles and an 18 wheeler on Hwy 49 South near Tchula, MS. The accident happened around 7:00 AM. The Cardinal driver had already made his deliveries to the facilities and only had the return packages (used doses) from the day before. According to RSO, driver hit the rear of the 18 wheeler after he made a sudden stop on the highway. According to RSO, all packages stayed secured and braced and their was no contamination or contents spilled out of the packages. Another driver was in route to location to pick up the other driver and the radioactive packages to return them to the Flowood facility. The material being transported was used doses of Tc-99m and there was no spillage or cleanup required. MS Report No. MS-493-01 | ||
| ENS 44139 | 19 March 2008 04:00:00 | Agreement State | Agreement State - Florida - Missing Dose of Tc-99M | The State provided the following information via facsimile: Cardinal Health reported that they are missing a single dose of Tech-99m, 25 mCi's since 19 March 2008. Customer reported item was not in ammo box upon receipt. Cardinal Health has searched premises with no indication. Procedures were reviewed and found to be correct. Corrective action consisted of a staff meeting to reiterate the requirement to follow proper procedure when packaging and shipping radioactive material. Incident referred to materials office for further investigation. This office will take no further action. FL Rpt No: FL08-056 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. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source | ||
| ENS 43841 | 19 November 2007 15:13:00 | Agreement State | Agreement State Report - Dose to Wrong Organs | The Agreement State of Louisiana submitted the following information: On Monday November 19, 2007, Cardinal Health Nuclear Pharmacy delivered an isotope dose labeled incorrectly. The dose delivered, was labeled Tc-99m Mertiatide (Mag-3) assayed at 5.1 milliCuries at 9:13 AM. The dose ordered was for a Renal Scan scheduled for 9:30 AM. After injection of the ordered dose, subsequent imaging revealed accumulation of radiopharmaceutical in the liver and spleen. The target organ for Mag-3 is the kidneys. The images would suggest Tc-99m Sulfur Colloid as the agent delivered. This information was reported by the facility that received the dose. The facility also notified Cardinal Health. This matter is under investigation by Louisiana DEQ. This report refers to Louisiana event identification number: LA070030. A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. | ||
| ENS 43731 | 24 September 2007 05:00:00 | Agreement State | Agreement State Report Involving an Improper Injection | The following information was received from the Louisiana Department of Environmental Quality via fax: On September 24, 2007, a customer called the pharmacy to inform them that a Tc-99m mertiatide prescription for renal imaging showed no renal distribution and instead showed only liver distribution. After an investigation by the licensee, it was determined that the error occurred in the pharmacy and all customers who could have been affected by the event were notified. Only one of the patients was injected. The radiation dose to the patient involved was minimal. Procedures not followed is the root cause of this incident. The corrective actions for this incident include retraining on policy and procedures regarding compounding doses. Event Report ID No.: LA070028
This event (EN43731) has been reviewed and determined to not meet the definition of a medical event. Notified R4DO (Proulx) and FSME EO (Flannery). | ||
| ENS 43432 | 16 May 2007 05:00:00 | Agreement State | Louisiana Agreement State Report - Medical Event Due to Dispensing Error | The State provided the following information via facsimile: Description of Event - A customer called the (Cardinal Health) pharmacy on Wednesday, May 16, 2007 to report that the late injection of Tc-99m sestamibi, a heart imaging agent, showed no heart uptake on the film. Instead there was only soft tissue uptake. The activity dispensed and injected matched the prescription. The next day the patient was brought back to the department and the image indicated that the dose injected was Tc-99m medronate, a bone imaging agent. Investigation and Root Causes - A large dose of Tc-99m sestamibi was ordered at 0600 calibrated for 1400. A biliary dose was also ordered at the same time. These were the only two doses drawn at that time. After notification by the hospital, an investigation revealed that the activity and volume remaining in the sestamibi vial plus the volume and activity dispensed matched the total volume and activity of the prepared kit (after correction for decay). The concentration for the sestamibi kit is normally 30% greater than for a bone imaging kit. Since the volume was correct, no flags were detected during dispensing. It is not Cardinal Health policy to test used syringes due to blood borne pathogen hazards. No other clients that were dispensed doses from the same vial reported errors in imaging. From this analysis, Cardinal Health can find no errors on its part to account for the imaging error. Actions Taken to Prevent a Recurrence - Cardinal Health has protocols in place to prevent dispensing errors of the type described above. Since the error cannot be attributed to Cardinal Health, corrective action is unnecessary. LA event Report ID No.: LA070015 A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. | ||
| ENS 43201 | 14 February 2007 06:00:00 | Agreement State | Agreement State Report - Dispensing Error for Thallium -201 Dose | The following information was provided by the state via facsimile: Description of Event: On February 14, 2007, a customer called to report that the Thallium-201 Chloride dose they ordered was only 2.9 mCi instead of the 4.0 mCi requested. Thallium-201 Chloride is an imaging agent used for myocardial perfusion imaging or parathyroid and tumor imaging. Another TI-201 dose was sent to the customer to account for the incorrect activity. An investigation revealed that the pharmacist who dispensed the dose had selected the incorrect setting on the dose calibrator when assaying the dose at the pharmacy. The dose calibrator was set on Tc-99m instead of TI-201, resulting in an incorrect assay. Root Causes: The root cause of this event was an error by the pharmacist while assaying the dose. By not double-checking that the dose calibrator was on the correct setting, an incorrect assay was recorded. Actions Taken to Prevent a Recurrence: In an effort to prevent a recurrence of this event, the pharmacist will be sure to check that the correct isotope settings are in place on the dose calibrator for the dose being assayed. Additionally, checking the volume on the dose label will help reinforce that the pharmacist has checked which dose is being assayed and if the isotope setting is correct. LA Event Report ID No.: LA070003
The State of Louisiana is retracting this report following a review which concluded that their reporting criteria was not met. Notified R4DO (Shannon) and FSME (Morell). | ||
| ENS 42999 | 16 November 2006 06:00:00 | Agreement State | Agreement State - Stolen Truck Containing Radiopharmiceuticals | The State provided the following information via email: DRH (Department of Radiation Health) received notification on 11-17-06 from Cardinal Health about a delivery vehicle that was car-jacked at a gas station located in Jackson, MS. The driver was driving a Ford Ranger delivery truck that was carrying approximately 540 millicuries of Technetium-99m. The vehicle was delivering radiopharmaceuticals to area hospitals and clinics. At the time of the report to DRH, the doses had already gone through 3 half-lives of decay. As of Monday 11-20-06, the vehicle has not been recovered. The State notified Flowood, MS and Jackson, MS police departments, Mississippi Emergency Management Agency (MEMA), and the FBI. Mississippi State report number: MS 06014
Vehicle recovered by Jackson Police Department 11-20-06 at about 2:00 PM CST. Ammo boxes (shipping containers) were not tampered with and all material recovered. Security seals were still attached. R4DO (Campbell), NMSS EO (Camper) and ILTAB (via e-mail) have been notified. 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. | ||
| ENS 42858 | 22 September 2006 11:00:00 | Agreement State | Agreement State Report - Traffic Accident Involving a Truck Carrying Radioactive Material | The State provided the following information via email: The Division of Radiation Health (DRH) received notification on 9-22-06 from Mississippi Emergency Management Agency about a traffic accident that occurred at 6:00 AM on Highway 43 North of Picayune, MS. The vehicle was delivering radiopharmaceuticals to area hospitals and clinics. The road was wet due to rain and the driver lost control of vehicle and collided with 2 other vehicles. Several of the shipping containers were ejected from the vehicle and some of the contents were deposited outside the shipping containers. Local sheriff department and fire departments responded to the accident scene. DRH responded to the scene of the accident as well as Cardinal Health personnel. Cardinal Health personnel discovered that no contamination had leaked from the containers and no personnel were contaminated. Vehicle was transporting 6 boxes (ammo boxes used as shipping containers) containing a total of 892 millicuries of Technetium-99m and Xenon-133. Some boxes contained used doses that had already decayed to near background radiation levels. Mississippi Incident Report number: MS 06011 See Louisiana Agreement State Report: Event Number 42855 | ||
| ENS 42624 | 22 May 2006 05:00:00 | Agreement State | Agreement State Report - Unsecured Delivery of Radioactive Material | The State provided the following information via facsimile: On May 22, 2006, a package containing 300 (microcuries) of I-123 in two (2) capsules was prepared for shipment at the Cardinal Health Nuclear Pharmacy Services ('Cardinal Health') facility in Dallas, TX. This package was a Type 7A container and was given a Yellow II label. This package was consigned to a contract courier, Tradewind, Inc., for delivery to Cardinal Health in Shreveport, LA. Delivery of this package to Cardinal Health Shreveport was attempted sometime after it closed at 5:00 PM. It was discovered by a parking lot cleaning crew at approximately 11:30 PM that evening. The package had been left behind a dumpster outside the pharmacy and covered with a Tradewind jacket. The cleaning crew contacted the police, who arrived at the scene shortly afterwards and contacted the fire department, who dispatched a HazMat team. The police also contacted our pharmacist on call by using the emergency contact number posted on the outer vestibule door to our pharmacy. The fire and/or police departments took control of the material until a representative from Cardinal Health arrived on site. All radioactive material listed on the shipping paper was present and accounted for. Root Causes: The cause of this event was a failure by the courier, Tradewind, to properly perform their contracted duties. The package in question was left unsecured behind a dumpster. This is not how Tradewind has been instructed to deliver packages to our pharmacy. They have been instructed to deliver radioactive material packages in a designated area (that is appropriately marked) inside the vestibule, in the rear of our building. Tradewind was issued a vestibule key for this sole purpose. The driver who originally arrived to deliver the package did not have the vestibule key. An interview with him revealed that his intent was for another Tradewind driver to arrive later with the key and deliver the package into (licensee's) secured vestibule. Actions Taken to Prevent a Recurrence: Cardinal Health will be working with Tradewind to review training documents required by the DOT and to formulate corrective measures taken to prevent reoccurrence of this type of event. LA Event Report ID No.: LA060008 | ||
| ENS 42441 | 22 March 2006 08:00:00 | Agreement State | Agreement State Report - Radiation Exposure | The State provided the following information via email: The Manager Health Physics, Cardinal Health called to report an incident which occurred today out of their Colton, CA pharmacy. A generator was being shipped via contract carrier from Colton to their Palm Springs pharmacy. The wrong shielding was used. Instead of a (Transportation Index) TI 1 which it was shipped as it was actually a TI 20. Upon arriving at the Palm Springs pharmacy it had a surface reading of 1,000 mr/hr. Estimate 4 hours with the driver. (The Manager Health Physics) was not aware if the driver had a personnel exposure device or what type of vehicle was utilized or the distance the generator was from the driver. CA Report Number: 032206 | ||
| ENS 42418 | 5 March 2006 06:00:00 | Agreement State | Agreement State Report - Patient Received Improper Medical Dose | The State provided the following information via facsimile: On March 5, 2006, a technician at St. Francis North Hospital contacted the Cardinal Health pharmacy to inform them that a scan on a patient had shown lung imaging instead of the expected cardiac imaging after administering a dose labeled Myoview. An investigation revealed that the customer's Tc-99m Myoview dose for cardiac imaging had mistakenly been dispensed as a Tc-99m MAA dose which is for lung imaging. The cause of this event was a failure by the dispensing pharmacist to follow proper Cardinal Health compounding procedures. The pharmacist pulled the wrong kit from the refrigerator. The pharmacist performed a QC test on the dose, but failed to label the starting point on the QC chromatography strip, which led to a misinterpretation of the failing test as a passing test. In order to prevent a recurrence of this event, the pharmacy is going to begin requiring all employees performing QC tests to label the starting point of all QC strips. Also, the pharmacy is planning to switch brands of MAA since the Drax MAA vial and the Myoview vials are identical in appearance. | ||
| ENS 42273 | 18 January 2006 06:00:00 | Agreement State | Agreement State Report of an Extremity Exposure Greater than Limit | The State provided the following information via email: A Nuclear Pharmacy Technician was preparing Tc-99m doses in a very busy pharmacy when his weekly extremity monitor reached an annual limit with a reading of 53,440 mrem for the calendar year of 2005. The licensee's corrective action includes additional training, possible modification of technique, and having corporate health physics staff investigate the incident. The dose was being monitored and management did not anticipate that the employee would exceed the maximum but he had a 'hard week' (12/26-01/06) where his right hand received 3,120 mrem. Corrective action will include hiring new techs since two other dose drawing techs have been 'benched' earlier in the year before their extremity doses would have exceeded the regulatory maximum. Reportedly the RSO and manager (redacted) did not receive the report until today. This is the 3rd busiest nuclear pharmacy in the world supplying ~1,000 doses/day to the greater Houston area. TX Event Report ID: TX-06-42273 TX Incident # I-8289 | ||
| ENS 42236 | 29 December 2005 16:45:00 | Agreement State | Agreement State Report - Transportation Accident Involving Used Technetium 99M Syringes | The Commonwealth of Massachusetts reported that there was a transportation accident on route 9 in Westborough, Massachusetts involving an overturned delivery truck returning used Technetium 99m medical diagnostic dose syringes. State police responded and closed the roadway. A hazardous materials team responded. A Commonwealth of Massachusetts Health Physicist also responded to the scene. Seven type A "ammo box" containers contained the used syringes. At least one of the boxes broke open. The doses were supplied by Cardinal Health of Woburn, Massachusetts. Originally it was estimated that 56 millicuries of Tc-99m was involved. In an update to the original report, the Massachusetts official determined through interviewing the driver of the vehicle, that the dose syringes were used. The responders took surveys of the area and detected no readings above normal background radiation levels. Local television news media responded to the scene. 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. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source | ||
| ENS 42223 | 22 December 2005 12:30:00 | Agreement State | Agreement State Report of Traffic Accident Involving Radioactive Material | A truck carrying 600 millicuries of Technetium-99m (150 ml in two containers) was involved in a traffic accident in Lawrence, Kansas. The containers were undamaged by the accident and a survey of the containers and truck determined that there was no leakage or radioactive contamination. The Technetium has been secured and taken into possession by representatives of Cardinal Health. Kansas Report # 7831227 | ||
| ENS 41840 | 26 June 2005 21:20:00 | Agreement State | Agreement State - Medical Sources Stolen | The theft occurred on June 26, 2005, at approximately 3:20 p.m. (The driver) had taken receipt of the cargo at the airport in Dallas (DFW), Texas, and he made the first delivery at a Cardinal pharmacy in Tyler, Texas. After the first delivery, he proceeded to the next stop, which was about one mile away. When he went to the back of the truck, he noticed that the canopy door had been pried open, but was still locked. When he looked inside, he noticed the box containing products for the Cardinal pharmacy was missing. The driver promptly notified (his) supervisor, who then contacted the Tyler Police and the Tyler Fire Department. The driver was personally interviewed that day by (Trade wind Enterprises - the shipper) and the Tyler Police Department. Efforts were made to locate the missing cargo, but police and the driver have been unable to locate the cargo or identify the person or persons involved in the theft. The materials stolen consisted of 6 boxes of sodium iodide capsules (I-123)." The activity in the missing capsules was 6.8 milliCuries." Police Report case: 1-05-029925 * * * UPDATE P. EGIDI TO P. SNYDER ON 7/26/05 AT 1656 * * * The State provided the following information via facsimile: Material found. Issue closed. R4DO (Graves) and NMSS EO (Giitter) notified. E-mailed to TAS (Hahn) | ||
| ENS 41469 | 8 March 2005 13:40:00 | Agreement State | Agreement State Report - Truck Containing Radiopharmaceuticals Stolen in Massachusetts | At approximately 0840 EST on 03/08/05 a truck operated by Cardinal Health (a Rhode Island licensee) was stolen while parked and unattended at a store in Seekonk, MA. The truck contained four unit doses of Tc-99m (total of 1.2 Curies) being delivered to a client of the licensee. The Seekonk, MA Police Department was notified and an investigation is in progress. No information is available on any planned reward or press release.
The truck was recovered in MA at approximately 2200 hours on 3/8/05. The rad material was found intact with the seals not disturbed or broken. RI Rad Health will inspect their licensee this week. Notified R1(Shanbaky), NMSS(Hickey) and TAS via email. | ||
| ENS 41351 | 20 January 2005 17:00:00 | Agreement State | Agreement State Report Involving a Pharmacy Spill of Samarium-153 | The following information was submitted by the licensee to the State of Colorado in an email dated 1/21/05 at 1137 hours: On 1-20-05 at approximately 10:00 Cardinal Health, location 48 (Colorado Springs, CO, License number 392-03) had a Sm-153 spill. Approximately 72 mCi of Sm-153 was spilled on the floor next to the main drawing station in the Lab. Our pharmacist was transferring a vial from the Berlex lead vial shield to our tungsten vial shield when the vial got away from him hitting the floor and breaking. The Pharmacist immediately notified the RSO and they started the decontamination process to minimize the risk of cross contamination into other areas of the lab. The area was segregated and the decontamination process was started. Radiacwash was used to decontaminate the area and all contaminated wipes, shoes, and associated materials were bag(ged) and placed with the Sm-153 waste. After initial decontamination was completed the area was surveyed and readings of 200 Mr/hr were obtained at the surface of the floor. Subsequent rounds of decontamination provided a reading of 50 Mr/hr. After we covered the area with padding and lead the exposure readings went down to 0.2 Mr/hr. Wipes were conducted of areas outside of the lead shielding on the floor and were found to be at background levels. We had a brief staff meeting of the pharmacists to access and evaluate the situation and to go over the proper procedures for transfer and dispensing of Sm-153 so that this incident would not be repeated. The corporate office was notified. The material will be allowed to decay for several days, at which point a determination of the levels of impurity contamination will be assessed. The floor will be removed, if needed, to reduce the exposure rate to acceptable levels. On 01-21-05 the Radiation Management unit of the State of Colorado, Department of Public Health was notified under section 4.52.2.2 (2) of the state regulations. A written response will be forwarded to the state within 30 days. | ||
| ENS 41306 | 1 January 2005 10:00:00 | Agreement State | Agreement State Report of Truck Crash Resulting in Minor Contamination and Loss of Radiopharmaceutical Vials | A truck carrying radiopharmaceuticals for Cardinal Health had an accident on Eastbound Route 50 near the Cape St. Claire exit in Annapolis MD. Police, Fire Department and an ambulance responded to the scene. The licensee's Radiation Safety Officer (RSO) also responded. Survey indicated contamination over an area of approximately 100 feet. It was determined that an 8 mCi vial of Tc99 MAA had been damaged and spilled during the accident. The Maryland Department of Environment and Hazmat were summoned. The area was decontaminated with a high-powered water spray. However, further investigation determined that an ammo can containing two vials of TC99m and TC99 MAA was missing at the accident scene. The two vials had a total activity of 566 mCi as of 0400 on 1/01/05. An extensive search of the area was unable to locate the ammo can with the two missing vials. Neither the licensee nor the Maryland Department of Environment believe that the vials pose any health risk since the Tc99m has a 6 hour half life. | ||
| ENS 41271 | 25 October 2004 20:00:00 | Agreement State | Agreement State Medical Event | The following information was received via facsimile: At 2:00PM on October 25, 2004, Saint Mary's Diagnostic Center reported that a Myoview dose was not showing the heart, but the sternum was viewable, indicating that the dose may have been MDP (bone agent). The syringe was retrieved from the customer and test confirmed the dose was MDP. The cause of the error was improper drug selection when filling the prescription. An in-service was conducted for the importance of detail when filling prescriptions and dispensing doses to correct the problem. The written notification was not received until December 13, 2004. LA Event Report ID - LA040014 | ||
| ENS 40936 | 9 August 2004 13:30:00 | Agreement State | Spill of I-131 Resulting in Contamination | On 08/09/04, Cardinal Health reported to the Wisconsin Department of Health and Family Services- Radiation Protection Section that the Cardinal Health Nuclear Pharmacy located in Madison, WI had a spill of approximately 50 milliCuries of an I-131 sodium iodide solution at approximately 0830 CDT on 08/09/04. Under Wisconsin regulations, HFS 157.13(17)(b)(1)(b), the licensee is required to report this within 24 hours. This preliminary report describes what the licensee initially reported. The licensee will provide a formal written report within 30 days as required by subsection (c) of the same section of the regulations. The spill occurred while transferring a stock bottle from a glovebox to a fume hood. The lead pig containing a vial of 50 milliCuries of I-131 slipped from the individual's hands, hit the floor and spilled some or all of the contents on the floor and adjacent areas. The pharmacy RSO evacuated the area and cleaned the spill to the extent possible. The vial and pig were double bagged and placed in the fume hood. Fixed contamination was covered with lead sheets and general radiation levels are less than 1 mR/hr. A spot on a door in the restricted area reads 10 mR/hr and they are attempting to decontaminate it. Pharmacy staff will pull air samples and will collect thyroid counts on all affected personnel. The pharmacy continues to operate. The Wisconsin Department of Health and Family Services dispatched a two person radiation survey team to the Cardinal Health Nuclear Pharmacy. | ||
| ENS 41833 | 2 May 2004 04:00:00 | Agreement State | Agreement State Report Involving a Potential Extremity Overexposure | The following information was received via facsimile: A radio pharmaceutical worker received an extremity dose for 2004 of 51 Rem according to her ring badge. 20 Rem of this dose occurred on April 26 - May 2. The licensee thought this may have been an erroneous reading so this is currently considered a potential extremity overexposure until further investigation. The radiation source is described as mostly Tc-99m with a dose received to the left ring finger of 51050 mRem. The time and date of discovery for this event was 1100 hours on 7/7/05. | ||
| ENS 40848 | 27 February 2004 05:00:00 | Agreement State | Lousiana Agreement State Report - Medical Event | The following information was obtained from the Louisiana Department of Environmental Quality: On February 27, 2004, Woman's Hospital in Baton Rouge, LA ordered a 2 (milliCuries) capsule of I-131 (Iodine-131). When the dose was sent it was 2.8 (milliCuries) which is greater that 10% of the prescribed dose. A verbal order was given to administer the dose to the patient. Woman's Hospital notified Cardinal Health of the irregularity on March 1, 2004 when they received the dose. The RSO (Radiation Safety Officer) notified the corporate office by fax of the irregularity but that person was not there and it went unnoticed until March 31, 2004. Cardinal Health notified LDEQ (Louisiana Department of Environmental Quality) on March 31, 2004 which was over the ten day limit for notifications. The facility was cited for not notifying LDEQ within ten days. Cardinal Health changed their procedures so that two people are notified of events, and the new pharmacist that made the dose received additional training on policies and procedures. Louisiana State Event Report ID number is LA040006. | ||
| ENS 40553 | 26 February 2004 21:00:00 | Agreement State | Agreement State Reports Spill at Nuclear Pharmacy | A syringe with 28 millicuries of Iodine-131 was stored inside a pig inside a hooded glove box. At 1500 CST on 2/26/04, the pig was knocked over, and the syringe broke. The contents of the syringe spilled into the hooded glove box. The spill was cleaned up. The glove box was ventilated and the ventilation system had a charcoal filter. It is estimated that 3 microcuries escaped to the atmosphere. Bioassays were performed on the 3 people involved in the spill and cleanup. No absorption was found. The charcoal filter and papers used in the glove box were placed in storage to allow the Iodine to decay. |