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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 55876 | 3 May 2022 07:00:00 | Agreement State | Lost I-125 Brachytherapy Seeds | The following was received from the California Department of Public Health Radiologic, Health Branch via email: The Radiation Safety Officer for UCSD ((University of California, San Diego)) contacted the Radiologic Health Branch regarding the loss of I-125 sealed sources. He also reported the loss to the CA State Warning Center (control no. 22-2532). A medical physicist at the Moore's Cancer Center at UCSD received a box that contained 4 packs of I-125 sealed sources instead of his expectation of 3 packs. The medical physicist removed 3 packs and set the packing box outside for recycling, believing it was empty. The cardboard box was taken away by environmental services staff and has possibly been taken to the on-campus recycling center. The pack contains approximately 6-7 I-125 medical brachytherapy seeds with combined activity of 2.3 millicuries. The seeds are sealed in a shielded, sterile pack. The expected exposure level is close to background radiation level outside of the shielded pack. UCSD sent health physicists to the recycling center to search for the missing package. 5010 Number: 050322 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 55368 | 20 July 2021 07:00:00 | Agreement State | Y-90 Brachytherapy Underdose | The following was received from the California Department of Public Health via email: A medical event per 10 CFR 35.3045 was determined to have occurred on July 20, 2021, during a liver cancer therapy procedure using Y-90 Nordion TheraSpheres via manual brachytherapy under 10CFR35.1000. Dose 1: AU prescribed activity of 109.5 mCi of Y-90 to the patient's liver: right lobe segments 5 and 8 and successfully delivered 104 mCi (95 percent). Dose 2: AU prescribed 153.0 mCi of Y-90 to the patient's liver: right lobe segments 6 and 7, but could only deliver 68.5 mCi (44.8 percent). During the procedure, blockage occurred in the delivery apparatus, specifically the microcatheter, that the authorized user was unable to clear to complete the procedure. Pre and post-procedural vial measurements were performed using a calibrated ion chamber by a trained CNMT (Certified Nuclear Medicine Technologist) on July 20, 2021. 5010 Number: 072121 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. |