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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 45050 | 6 May 2009 07:00:00 | Agreement State | Agreement State Report- Missing Sealed Sources | UCLA was unable to locate 2 sealed sources which were listed in their inventory database. The first source was 50 micro Ci Co 60 as of 5/1/2000. Current activity is 15.28 micro Ci which exceeds the 1 microCi 24 hour reporting requirement. The second source was listed in their database as 1.83 micro Ci of Cm 244 as of 10/12/1988. UCLA believes the original activity for the Cm 244 source to be 1.83 nano Ci, and was listed incorrectly in their database. They contacted the Manufacturer, Isotope Products Laboratory, who informed them that they did not manufacture micro Curie quantities, but only nano Curie quantities of Cm 244. The current activity of the Cm 244 source (decayed to date of notification) is either 832 nano Curies or 0.832 nano Curies. The former exceeds the 1 nano Ci 24 hour reportable quantity requirements. UCLA believes the Cm 244 Source was installed in an instrument, but they were unable to locate the instrument at the time of notification. UCLA is continuing to search for the missing sources. The UCLA RSO (Radiation Safety Officer) believes the sources are still on the campus. 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 44321 | 23 June 2008 07:00:00 | Agreement State | Potential Underdose to Patient Undergoing Whole Body Radiation | The following report was received from the state via e-mail: On June 25, 2008 at approximately 3 pm, RHB received preliminary notification of a medical event, which occurred June 23, 2008, involving a 50% under-dose to a patient undergoing whole-body irradiation with a Co-60 teletherapy unit. The event was discovered at approximately 2 pm on June 25, 2008. RHB held the initial report to NRC until additional details could be provided by the licensee, who was still reviewing the situation with the radiation oncology department. The prescription was for total body irradiation at 17.12 minutes AP (anterior posterior), then 17.13 minutes AP, then 17.12 minutes PA (posterior anterior), then 17.13 minutes PA, for a total of 34.25 minutes AP and 34.25 minutes PA, and a total of 300 cGy. The therapist only treated 17.13 minutes AP and 17.13 minutes PA for a total dose of 150 cGy. The patient was seen by the attending physician on 6/25/08, with no known medical effects observed. There is currently no plan to re-treat the patient per the attending physician. The licensee is following up with a written report. 5010 Number - 062508 The attending physician and patient have been notified. 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. |