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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 56065 | 23 August 2022 16:00:00 | Agreement State | Lost Radioactive Portable Gauge | The following information was received via email: The Georgia Department of Natural Resources, Environmental Protection Division, Air Protection Branch sent this as notification that a lost portable gauge reported. The incident occurred 8/23/22 around lunch time and was reported to (Environmental Protection Division) (EPD) at (1530 EDT). The gauge is a Humboldt Model 5001. It is currently unknown which Isotope it contained or its activity (Cs-137 or Am-241). The gauge user was onsite and had placed the gauge on the tailgate of his truck. He left for lunch and when he got to the location, realized he had forgot to secure the gauge in it's transport box. The gauge was no longer on the vehicle. He reported the lost gauge to the local police and went back to look for the gauge. (The driver was unable to locate the gauge). We (EDP) are following up for more information, but wanted to meet our reporting requirements and inform you of the loss. The following additional information was obtained from the state in accordance with Headquarters Operations Officers Report Guidance: The license number, the county, and the worst case scenario activity for the Humboldt Model 5001 gauge (44mCi of Am-241). 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 54882 | 2 September 2020 04:00:00 | Agreement State | Agreement State Report - Medical Event - Underdose | The following was received from the Georgia Radioactive Materials Program via email: At the end of the administration of Y-90 SIR Spheres (for the treatment of tumors in the right lobe of the liver), the delivery vial (D-Vial) appeared to overfill as the radiologist was attempting to mix the spheres with a 50/50 solution of contrast and 5 percent dextrose/glucose (D5W). The radiologist noticed some clumping and after attempting to gently disperse the Spheres, he gave a couple hard pushes of the contrast/D5W into the D-Vial. At that time, he noticed the leak. He examined the septum and found it to be dry. As a precaution the radiologist put Durabond on top of the septum. Further examination showed that the material leaked out of the sides of the crimped vial top rather than the septum. The procedure was stopped to prevent further contamination. The event occurred while using SIRTEX new SIROS delivery system. The SIRTEX representative was present providing guidance to the radiologist as this was the first time he used the new system. It is estimated that 75 percent of Y-90 SIR-Spheres were administered to the patient (Prescribed Activity: 3.1 GBq (83.7 mCi); Delivered Activity (estimated): 2.87 Gbq (77.7 mCi)). It is likely that the residual activity was over estimated due to contamination of the SIROS delivery dome. The usual waste from the procedure is contained in a 1-liter Nalgene containers and then placed in a Lucite shield for dose rate measurements to determine the residual activity. The Siros delivery dome could not be measured in the same geometry and likely resulted in an increased dose rate and underestimate of the total dose delivered. At this time, the prescribing physician indicated he does not expect any adverse effects for the patient and is awaiting the dosimetry evaluation from the patients PET/CT Scan. Attempts have been made to recreate the event without success. There is speculation regarding the size of the dose and that the number of Spheres may have been a factor (larger than typically administered). Representatives from SIRTEX indicate that this has not been an issue at other sites. Prior and subsequent studies with the new SIROS delivery system were successful with less activity. Further evaluation of the equipment to determine why the vial leaked, will be performed following decay and return the manufacturer. Georgia Incident Number: 30 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 54879 | 27 August 2020 04:00:00 | Agreement State | Agreement State Report - Loss of Medical Seed After Removal from Patient | The following is a synopsis of the event received from the Georgia Radioactive Materials Program: On July 31, 2020, a physician did not follow proper procedure while recording the number of seeds administered to a patient. The physician initially planned on administering one seed but decided to administer two. The physician did remove both seeds from the patient on August 3, 2020. The tracking system for the administered seeds was based on writing the number of seeds administered on a colored bracelet or arm band, which the patient wears while the seed(s) are implanted. It is removed and travels with the removed tissue through the remaining processes at the hospital. In this case, the physician did not revise the number on the bracelet, therefore during the subsequent processes, other hospital staff only looked for one seed to recover from the procedure by-products. One seed was not recovered. There was some discussion between departments prior to August 21, 2020 about the seed. Radiation Safety was not contacted. On August 21, 2020, an Assistant RSO discovered the discrepancy while conducting an inventory, preparing the seeds for return to the seed vendor. Subsequent searches that included the involved staff did not recover the missing seed. After a review of the laboratory processes for analyzing the removed tissue, the hospital staff believes the missing seed was retained in the transport bin and disposed of with that bin in the bio-hazard waste stream. But, this can not be proven. It was demonstrated to not be in the frozen sample that the hospital retained. The hospital declared the seed lost on August 27, 2020. The seeds were I-125 encapsulated in titanium. Model IAI-125A. Activity level calculated to be 145.1 microCuries at time of loss/disposal. The radioactivity is small, and the decay rate high such that this poses a low risk to the public. Based on literature, the RSO states the contact dose, assuming the seed was trapped in clothing (contact) for twelve hours to be 2.66 milliSeverts. The hospital has conducted a root cause analysis, and has revised its procedures and re-trained staff to prelude future loss of radioactive seeds. Incident #: 29 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 54817 | 21 July 2020 04:00:00 | Agreement State | EN Revision Imported Date : 10/16/2020 AGREEMENT STATE REPORT - BROKEN SHUTTER The following is a summary of information received via email: On July 21, 2020, the licensee was conducting a semi-annual leak test and inventory when they discovered a shutter was not working on an in service source device. The source has been barricaded and appropriate warnings have been posted. An offsite technician is being contacted to replace the device. The device is an Ohmart Model A-2102 density gauge with a 100 mCi Cs-137 source.
The following is a summary of information received via email: The broken shutter concerned in this event was stuck in the open position. Notified R1DO (Arner) and NMSS Event Notifications via email.
The following update was received from the state of Georgia via email: A qualified technician from BBP installed the new source on September 23, 2020. The old source was sent back to QSA (Global, Inc.) with a confirmation receipt (dated October 2, 2020). Notified R1DO (Jackson) and NMSS Events Notification via email. | |||
| ENS 54694 | 4 May 2020 04:00:00 | Agreement State | Agreement State Report - Patient Underdose | The following was received via email: On 5/4/20, Piedmont Athens Regional Medical Center (GA 4-1) experienced a misadministration of BTG's TheraSphere Y-90 product. The plan of treatment was for (the treating physician) to deliver 120 Gy to the patient's left hepatic lobe with 1.62 GBq (43.78 milliCuries) of Y-90. The treating physician positioned the microcatheter in the left hepatic artery and verified positioning with a left hepatic arteriogram. With the microcatheter in this position, the treating physician began administering the microspheres. However, only a portion of the dose was delivered as the catheter quickly became occluded. Because of the patient's tortuous hepatic vasculature, the assessment is that a kink in the microcatheter prevented the majority of the dose from being delivered. The delivered activity was calculated by comparing pre- and post-treatment survey meter measurements of the administration equipment as outlined in TheraSphere's administration procedure. The delivered activity to the patient was 0.28 GBq (7.52 milliCuries). The delivered activity is approximately 83 percent less than the prescribed activity. Post treatment surveys of all gowns, syringes, gloves, drapes, floor coverings, and trash revealed no contamination of the surgical suite. Post treatment planar imaging revealed no extrahepatic deposition of activity. The treating physician explained our inability to deliver the full dose with the patient and a plan was made for the patient to return on 6/5/20 for a second attempt at treating the left hepatic lobe. 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 54662 | 31 March 2020 04:00:00 | Agreement State | Agreement State Report - Loss of Iodine-125 Seed | The following was received from the state of Georgia via email: An Iodine-125 seed (assayed at 69 microCuries on March 24, 2020 (Best Model 10172-11, Double wall titanium encapsulated, Serial Number: 49802A20)) used for breast lesion localization was shipped within a tissue specimen from Piedmont Fayette Hospital to Piedmont Atlanta and then lost into the ordinary solid waste stream, rather than being recovered and placed in decay-in-storage at Piedmont Fayette, as is the standard procedure. The seed was implanted in a patient with a breast lesion at Piedmont Fayette on March 24, 2020. The lesion containing the seed was successfully removed in surgery and sent to the pathology lab on March 30, 2020. The presence of the seed in the specimen was verified in pathology by Neoprobe measurement. There was no pathology physician assistant present that day and the pathologist was not notified. A lab staff member arranged for all specimens to be shipped to Piedmont Atlanta. The specimens, including the one containing the seed, were shipped by MedSpeed courier service that same day. At the Atlanta campus, the specimen with the seed was processed by the normal procedure on April 1, 2020. The histotechnologist there removed what he thought was a marker or a clip and discarded it in the regular waste bin. The waste containing the seed was removed from the Atlanta campus (in a bag of solid waste) and transported to the (Pine Ridge Regional Landfill) by the waste disposal company's normal procedure on or around April 2, 2020. (The Radiation Safety Officer (RSO)) was notified by phone on April 3, 2020 and searches of all relevant areas at Piedmont Atlanta were performed by staff using a GM survey meter with pancake probe as well as with a Sodium Iodide scintillator probe that day. No evidence of radiation or the seed was found in any location. The proper course of action that should have been taken in order to prevent this situation is as follows: The pathologist at Fayette should have been notified that there was a specimen with a radioactive seed. The pathologist would have removed the seed and the pathology staff would have contacted Nuclear Medicine to retrieve the seed and place it in decay-in-storage. Seeds should not leave the Fayette Campus. In (the RSO's) estimation, it is unlikely that any occupationally exposed worker or member of the public received any significant exposure or exceeded any dose limit. All staff in pathology have been educated on the circumstances that led to this incident. The procedure has been updated to clarify what actions should be taken if a specimen with a seed arrives in pathology when no pathology physician assistant is present. Knowledge of this procedure has been added to the competency checklist for pathology employees. 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 54110 | 11 June 2019 04:00:00 | Agreement State | Agreement State Report - Patient Under Dosage Due to Air Being Trapped in the Delivery Line | The following report was received from the Georgia Department of Natural Resources via email: A TheraSphere Y-90 patient did not receive the full dose to the target organ that was prescribed. The administered dose differed from the prescribed dose by more than 20 (percent). The prescribed activity to be delivered to the patient was 2.15 GBq (58 mCi). The calculated delivered activity to the patient was 1.01 GBq (27.3 mCi). The delivered activity was determined by comparing pre-and post-administration survey meter measurements of the administration equipment, as per standard TheraSphere procedure. Radiological Analysis: Prescribed dose to target volume (liver): 127 Gy Administered dose to target volume (liver): 59.8 Gy Discussion and Outcome: On May 28, 2019, it was brought to the radiation safety officer's attention that a Y-90 TheraSphere administration had not delivered the full prescribed activity to the patient as intended. Upon further discussion it was noted that the performing physician noticed after connection of the line between the micro-catheter and the delivery vial that multiple air bubbles had become trapped in the line. He then created a closed system manifold using a three-way stopcock and syringes to effectively bleed out air bubbles and flush back as much of the dose as possible to the patient. The closed system prevented any spillage or contamination, and residual dose was retained in the syringes and stopcocks. Despite these actions taken by the physician, a post-administration assay of the waste container showed that the full desired activity had not made it out of the delivery equipment and into the patient. The procedure was a segmentectomy, and (the) patient will be re-evaluated in one month's time to determine if an additional therapeutic administration will be needed. Root Cause: Human error: Air was likely trapped somewhere in the system during the initial setup of the equipment. Operator technique failed to completely purge the lines of this air. Air bubbles in the line were not visible or not noticed prior to the connection of the line. Efforts to eliminate the air and deliver the full dose to the patient were then not successful. Corrective Actions and Actions to Prevent Further Occurrences: The nature of this event and the likely cause has been discussed with all staff involved in these procedures. A refresher training session has been scheduled for staff involved in these procedures. This training will be provided by a representative from BTG/TheraSphere starting on June 10, 2019. An additional step will be added to the procedure to visually and verbally confirm that there is no detectable air in the line between the micro-catheter and the dose vial prior to connection.
The NMED report number from the original report was removed. The new NMED report number was not obtained. NRC Event number 54684 was also created for this event and was deleted from the database. Notified R1DO (Schroeder) and NMSS Event Notification (email). 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 54549 | 2 May 2019 05:00:00 | Agreement State | Agreement State Report - Broken Density Gauge Shutter | The following is a summary of emails received from the Georgia Department of Natural Resources (the state): On 05/02/2019, the licensee discovered a broken shutter on an Ohmart DSGX GEN2000 fixed density gauge during semi-annual leak testing. The gauge is roughly 15 to 20 feet in the air and contained a 20 mCi Cs-137 source (A-2102 source/SN 61798). The source was barricaded and warnings posted. The source was determined not to be leaking. At the time a reactive inspection was performed. On 08/01/2019, an update was sent to the state. An offsite authorized technician attempted to repair the shutter but was unsuccessful. The radiation source remained in service and barricaded and the RSO continued to actively monitor the source with no leakage detected. The licensee was obtaining a quote for removal/proper disposal and the purchase of a new radiation source for replacement, but the source continues to be operational with no additional risk to workers. The incident was closed on 08/01/2019. Incident Report No.: GA-2019-15
Gauge was replaced and sent to QSA Global for disposal. Source was received at QSA Global on 01/13/2020 and verified to not be leaking. Notified R1DO (Ferdas) and NMSS Event Notification (email). | ||
| ENS 53996 | 3 April 2019 04:00:00 | Agreement State | Agreement State Report - Underdose Administration of Y-90 Theraspheres | The following is a synopsis of the information received from the Radioactive Materials Program of Georgia received via email: On April 3, 2019, an underdose of Y-90 TheraSpheres was administered to a patient. Only 65% of the prescribed dose was administered. On April 5, 2019, the remainder of the prescribed dose was delivered to the patient. There is no definitive cause identified at this time but the licensee has concluded that it was probably a delivery equipment problem (perhaps with the tubing). The licensee will follow-up with a formal report.
The state of Georgia amended the original report to state that the deliver apparatus is awaiting decay to background and will be examined locally or will be sent to the manufacturer for a root cause analysis. The prescribed dose was 127 Gy. The delivered dose was 59.8 Gy which is 47% of prescribed dose. As stated above, the patient was informed and returned two days later to complete the treatment. NMED Item: 190182 Notified R1DO (Schroeder) and NMSS Events Notification (email).
The state of Georgia has amended the original report and the update from 4/29/20 as follows: -the prescribed dose was 122 Gy -the delivered dose was 78.8 Gy -the difference is 64.5 percent. This same event was also reported under NRC Event Notification #54010 which has been deleted from the report database. Notified R1DO (Schroeder) and NMSS Events Notification (email). 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 54550 | 18 January 2019 05:00:00 | Agreement State | Agreement State Report - Improper Disposal of I-125 Seed | The following is a summary of emails received from the Georgia Department of Natural Resources (the state): On 01/18/2019, the licensee performed a Radioactive Seed Localization (RSL) using 81 microCi of I-125. The tissue and seed were transported to pathology where the pathologist misidentified the seed as a straight clip-non-radioactive and the material was designated for disposal. The Nuclear Technologist realized on 02/06/2019, through paperwork, that the seed could not be accounted for and had improperly gone out through the ordinary waste process at the hospital. On 03/04/2019, the state's reactive inspection report found that the RSL procedure was a two seed implantation. A documentation problem occurred when two separate I-125 seed tracking documents were used instead of one. When the tissue containing the seeds was excised and taken to pathology in a cup, only a single document showing one seed implant made it to pathology. The second document did not arrive, so pathology was unaware that there were two seed implants. This led to one of the seeds being mistaken for a clip. The cup that the tissue was transported in was surveyed at pathology and there was the expected readout, which was attributed to a single seed. Corrective actions include to document seeds acquired for implantation on a single sheet of paper. Efforts were being made to discontinue the RSL program and replace it with a radiofrequency seed localization system that involves no radioactivity. The incident was closed on 03/04 2019. Incident Report No.: GA-2019-10 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 54541 | 18 December 2018 05:00:00 | Agreement State | Agreement State Report - Leaking Promethium-147 Source | The following information was received from the state of Georgia via email: On December 11, 2018, (Honeywell International) tested a sealed source for leakage or contamination and received results on December 21, 2018. The result from (their) vendor (was) 0.0113 +/- 0.0002 microCuries. This result is above the limit of 0.005 microCuries. The capsule has been isolated and there (was) no loose contamination detected in (their) facility. (Honeywell) will contact the vendor and arrange to return the capsule after the new year. The source capsule, Model PHC.C2, serial no. AE5051, was manufactured with 2 Ci of Pm-147. The capsule was returned to Eckert & Ziegler who received it on 3/4/2019. The state of Georgia considers this matter closed. NMED Incident # 190022 | ||
| ENS 54565 | 29 June 2018 05:00:00 | Agreement State | Agreement State Report - Lost Iodine-125 Seed | The following information was received from the State of Georgia via email: On June 29, 2018, it was brought to the (Piedmont Fayette Hospital Radiation Safety Officer's) RSO's attention that a radioactive seed containing 62 microCuries of Iodine-125 was unaccounted for and could not be located. The seed was manufactured by Best Medical International, Inc., Model 2301. The physical form is a double wall titanium tube containing a tungsten x-ray marker that is coated with I-125. The source serial/lot number is 45876A-26. The source was calibrated at 100 microCuries on 5/11/2018. On the morning of the seed implantation procedure, 6/27/2018, the source measured at 62 microCuries in the dose calibrator in the hot lab. The seed had been used for localization of a breast lesion. Tissue was extracted from the patient and the specimen was reported to have contained the seed at the time of specimen radiography. Following this radiography procedure, the seed appears to have been lost. All efforts were made by staff on-site to locate and search for the seed in all possible locations, with no success. The patient was brought back in for radiology procedures to ensure that the seed was not still contained in the patient. Results of x-rays showed that the seed was not present in the patient. According to the RSO, it is likely that the seed was disposed of along with the trash collected after the procedure, or possibly washed down the floor drain in the specimen radiography room. According to the RSO, this is a best guess as to the fate of the seed. No individual members of the public or staff were likely to have been exposed to significant doses of radiation, based on the available information submitted to EPD (Georgia Environmental Protection Division). 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 54537 | 3 April 2018 05:00:00 | Agreement State | Agreement State Report - Stuck Open Shutter | The following is a synopsis of a email from the state of Georgia: On April 3, 2018, the Georgia Radioactive Material Program was informed that a fixed nuclear gauge on the number 4 Digester had a shutter stuck in the open position (normal operation mode). The shutter was made operable on the same day, that the report was made to the state of Georgia. The gauge is a Kay Ray 7063-P and serial number 9132. The gauge contains 500 mCi of Cs-137. The gauge is in service with all radiation readings acceptable. There was no risk of exposure to employees or members of the public. | ||
| ENS 54563 | 6 November 2017 05:00:00 | Agreement State | Agreement State Report - Leaking Cesium-137 Source | The following information was received from the State of Georgia via email: (The Radiation Safety Officer) of Phoenix Technology reported a leaking cesium-137 source from one of their clients (Myers Cardiology). During a source change out on November 6, 2017, it was noted that the old source was leaking. The activity of the leaking source is 203 microCuries, and the leak test results are 26 nanoCuries. The leaking source was placed inside a protective pig and inside a plastic bag labeled as a damaged source. The source has been sent to Pinestar Technologies in Pennsylvania for proper disposal. Source Manufacturer: IPL Source Model No.: MED-3550 Source Serial No.: 986-15-17 Georgia Item Number: GA170001 | ||
| ENS 54644 | 9 June 2017 04:00:00 | Agreement State | Agreement State Report - Stuck Shutter | The following is a summary of information provided by the State of Georgia via E-mail: Licensee personnel were performing three year wipe tests when one gauge was found to have a stuck shutter. The gauge contained a Cesium-137 source (Device: Model D14400S, S/N SE4029, Source; 250 milliCuries; S/N SNC250066). The gauge was not in service at the time of the wipe test. The licensee is planning on selling the gauge and having it removed from the premises. The company buying the gauge is aware of the stuck shutter and will fix the shutter before removing it from the licensee's premises. | ||
| ENS 54564 | 9 August 2016 05:00:00 | Agreement State | Agreement State Report - Lost I-125 Source | The following was received from the State of Georgia via e-mail: The Georgia Radiation Materials Program received a call from the (Radiation Safety Officer) RSO from Grady Memorial Hospital on August 12, 2016, stating the (200 microCurie) I-125 seed used for localization of non-palpable lesions was lost. The doctor performing the procedure stated the seed went into the tube of the suction tank. A survey of the suction tank, hallways and operating room did not uncover the lost source. The tissue, removed from the patient, which was transferred to pathology, also did not contain the source. The surveys of the hallway and operating room were performed after the hospital was notified. The RSO recommends bringing the patient back in the hospital to be surveyed to verify if the source was ever removed from the patient. At the time of the call, the RSO has been unable to speak to the doctor. The doctor is a surgeon and not an authorized user. The RSO stated the tube to the suction tank cannot be found and it may have made its way into the biohazard container. The RSO will follow-up with the biohazard department to see if the tube can be traced down so the tube can be surveyed to determine if the source became lodged within it. The RSO is also trying to follow-up with the doctor for more information. NMED Report ID: 160362 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 |