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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 55142 | 11 March 2021 05:00:00 | Agreement State | Dose Received Was Less than Prescribed Dose | The following was received via an email from the state of North Carolina: Licensee reported that on March 11, 2021, a medical event occurred where the dose difference (from Iodine 131 is greater than 20 percent from the prescribed dosage). The prescribed dosage (by written directive) was 949 milliCuries; but the administered dose is estimated at this time to be about 507 milliCuries, which is 53% of the prescribed dose. The cause was a leaking tube from the infusion system. The bone marrow dose needed by the patient was considered sufficient, so there was no negative impact to the patient. An investigation by the North Carolina Radioactive Materials Branch is ongoing at this time. The radiopharmaceutical administered was Iomab-B (Iodine-131). North Carolina Tracking Number: 210003. 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 53881 | 16 February 2019 05:00:00 | Agreement State | Agreement State Report - Iridium 192 Seeds Lost During Medical Treatment | The following was received from the state of North Carolina via email. A patient underwent an Interstitial OBGYN Implantation on 2/14/19, consisting of 45 seeds of Iridium 192 (5 seeds per strand; total of 9 strands) with an activity of 34.1 mCi. The morning of 2/16/19, the patient, still located at the licensee's facility, removed the strands containing the sources, placing some in the room's trash and some in the toilet and flushed the sources. Four strands containing 20 seeds were flushed and the remainder in the room were recovered by radiation safety. The licensee confirmed surveys of the patient and room. No other sources were found. The patient room had been isolated when licensee personnel found the patient with the removed sources. The licensee's maintenance crew determined that waste pipes from the room were accessible through confined space entry via manholes to sewer system only. The NC RPS (North Carolina Radiation Protection Section) dispatched an investigator as soon as it was notified, same day. The licensee will not be pursuing the collection of these sources due to the added hazards of attempting searches in a sewer system." North Carolina Event Tracking ID 190003 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 |