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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 42570 | 5 May 2006 07:00:00 | Agreement State | Agreement State Report from California - Missing Source | The following is a summary of information provided by the State via facsimile: The RSO and medical physicist for Century City Doctors Hospital (CCDH) called to report a lost Sr-90 eye applicator, sn 1244, approx 28 mCi (was 63.3 mCi in 1972.) Century City Hospital closed in June 2005. It was reopened under a new entity as CCDH in November 2005. In December 2004 CCDH had sent its old Cs-137 brachytherapy sources to Barnwell. CCDH kept its dose calibrator sources & the Sr-90 eye applicator locked in their hot lab. CCDH is reopening its nuclear medicine department and asked the RSO to determine the status of the dose calibrator sources. When the RSO went to the hot lab on May 5, he noticed the Sr-90 source was missing. The old dose calibrator sources, which had decayed, were still there, and the RSO said it appeared no one had been in the hot lab- it was dusty and dirty. CCDH had a company, Dan York, perform wipe tests in March 2005. The hospital claims to have paperwork that indicates the Sr-90 source was wipe tested, but York says it wasn't. (The RSO will be reviewing that paperwork tomorrow.) Regardless, when York did the next wipe tests in Sept 2005, the eye applicator wasn't there at that time. So it's been missing since at least Sept 2005. The company who brokered the disposal of the Cs-137 sources, New World Technology, has been contacted, and they say they did not remove the eye applicator. The RSO will interview the physician who had used the applicator and everyone who had access to the hot lab. The hospital CEO will send a memo to hospital staff, asking if anyone has seen it. CA report number 051106 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. |