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| Entered date | Event description | |
|---|---|---|
| ENS 48715 | 5 February 2013 10:20:00 | On February 2, 2013 an individual called the Wisconsin Emergency Management duty officer to report found radioactive material. The duty officer notified the State Radiological Coordinator who responded to the member of the public. The individual reported that his mother had inadvertently brought home a radioactive source that had come from a donation drop-box. The source was reportedly labeled 'Radioactive Tritium', '4 mCi' and 'Self-Powered Lighting' and dated 8-19-1992. The State Radiological Coordinator ascertained the source was safely stored in the mother's garage in a cardboard box. State inspectors performed a site visit on February 4, 2013. The radioactive material was actually two 4 Curie tritium sources, Model CPI 300, Serial Numbers 1469 and 1470. Also, the sources were labeled NYS License Number 1406-1611 and parts P/N CAN/AC/4E. The Radiation Protection Section contacted Self-Powered Lighting and the individual stated that this was an aircraft device and that they would accept the source back. The state inspectors surveyed, wiped, and bagged the sources. Wipes will be analyzed by the Wisconsin State Lab of Hygiene. The sources were retrieved and are currently stored at the State's orphan source storage location. If the wipes confirm no contamination, the sources will be returned to Self-Powered Lighting or an authorized recipient. Wisconsin Report No.: WI130003 |
| ENS 48224 | 23 August 2012 13:00:00 | The following report was received from the Wisconsin Radiation Protection Section via e-mail: On August 20, 2012, at 1:30 pm the Wisconsin Radiation Protection Section, received a telephone notification from NRC Region III personnel that 10 tritium exit signs, that originally contained 7.5 Ci at the time of purchase 7-10 years ago, were placed in a compactor and damaged at a PSC Environmental Services, LLC facility in Detroit, Michigan (refer to NRC event notification #48205). The ten exit signs came from a Bed Bath & Beyond store in Wausau, WI. On August 20, 2012 at 2:00 pm, the Vice President of Loss Prevention and Safety was contacted and he informed the state that 14 tritium exit signs were being replaced with LED signs (this is being done nation-wide at all Bed Bath & Beyond stores) at the Wausau location and were intended to be returned to the manufacturer for disposal. The 4 remaining signs are in a secure location within the store. The Wisconsin Radiation Protection Section will be performing a site visit in Wausau to verify the four remaining signs are intact and will be performing an investigation into the root cause of this incident. Wisconsin Report: WI120011 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 This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source |
| ENS 47762 | 22 March 2012 17:35:00 | The State of Wisconsin provided the following information via e-mail: On March 22, 2012 at 2:30pm the Wisconsin Radiation Protection Section received a telephone notification that a fire had occurred at the licensee's location while performing a lung perfusion study at 11:45am, utilizing a 60 mCi dose of Tc-99m DTPA. The lung perfusion kit being used was a Biodex Medical Systems model Aerotech 1, lot #: 07811324. Per a discussion with the RSO, a patient was receiving a lung perfusion study when the perfusion kit 'burst into flames.' The Nuclear Medicine Technician (NMT) removed the face mask from the patient and the patient's hair caught on fire and the NMT put the fire out with their hands. The patient was immediately taken to the Emergency Room and the first degree burns on their face and neck have been treated. The area has been secured and surveys are in progress. The licensee will not be conducting any nuclear medicine procedures until the Radiation Protection Section has completed our investigation. WI Event Report ID: WI120002. |
| ENS 47135 | 9 August 2011 12:26:00 | The following was received via fax: The Wisconsin Department of Health Services (DHS) received a phone call from the Radiation Safety Officer (RSO) on August 8, 2011 that a patient received a dose of 1.05 GBq of Y-90 Theraspheres on July 7, 2011 to the wrong side of the liver as documented on the written directive. The patient was scheduled for treatment of 1.04 GBq Y-90 Theraspheres for multinodular hepatocellular cancer (HCC) to the left lobe of the liver. The dosimetry for Y-90 Theraspheres was based on volume (mass) of the lobe bearing the tumors (the patient has tumors on both lobes, right and left). A treatment plan was created for the left lobe (using the volume of the left lobe) but during the procedure the right lobe was treated with the prescribed dose for the left lobe. DHS will be conducting an investigation on August 12, 2011 and the licensee will be submitting a 15 day written report concerning the medical event. WI Event Number: 110012 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 47090 | 22 July 2011 16:29:00 | The following report was received from the State of Wisconsin via fax: The Wisconsin Department of Health Services (DHS) received a phone call from the Radiation Safety Officer (RSO) on July 22, 2011 that a patient received the wrong dose of I-131 on July 21, 2011. The patient was scheduled for a diagnostic procedure involving 8 mCi of I-131, but instead received a 150 mCi therapeutic dose of I-131. DHS will be conducting an investigation on July 26, 2011 and the licensee will be submitting a 15 day written report concerning the medical event. Wisconsin Event Report ID No.: WI10010
This is an update to (the State of Wisconsin) Event Notification WI-10010. On July 26, 2011, the licensee informed (the Wisconsin Department of Health Services) that the reported medical event on July 22, 2011 involving a patient that received 150 mCi dose of I-131 on July 21, 2011, was an internal miscommunication. Upon review of the written directive and speaking with UW-Madison staff, DHS has verified that the patient received an I-131 therapeutic dose as prescribed on the written directive. This medical event is retracted." R3DO (Giessner) and FSME EO (McIntosh) notified. |
| ENS 46574 | 27 January 2011 15:43:00 | The following report was received via fax: On January 27, 2011, the licensee's Radiation Safety Officer reported the identification of three medical events that were discovered on January 26, 2011, involving permanent implants of Pd-103 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. During a recent routine inspection, DHS (Wisconsin Department of Health Services) inspectors determined that the licensee was not reviewing prostate brachytherapy cases against the medical event criteria. The licensee established dose based criteria used by post-operation CT, prostate D90 values < 80% or >160% for classifying medical events. The licensee has evaluated all prostate implants performed since April 24, 2008. The licensee has notified the referring physicians and the referring physicians will not be notifying the patients. Case 1, November 2008: Prescribed dose 100 Gy. Prostate D90 was 77%. Case 2, April 2009: Prescribed dose 100 Gy. Prostate D90 was 71%. Case 3, October 2009: Prescribed dose 125 Gy. Prostate D90 was 78%. DHS inspectors are investigating these medical events and will send a special inspection team following the receipt of the licensee's 15 day report. Wisconsin Report Number: WI110003 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 46528 | 10 January 2011 14:29:00 | The following was received from the state via fax; In July 2010, the Wisconsin Department of Health Services (DHS) sent out an Information Notice to all licensees who perform prostate brachytherapy and asked them to perform a comprehensive review of all prostate brachytherapy cases to determine whether any medical events had occurred. On January 10, 2011, the licensee's Radiation Safely Officer reported the identification of five medical events involving permanent implants of I-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. The licensee is identifying a medical event of any case where D90<135 Gy or D90>195 Gy for patients who receive seed implants only. (D90 is a recognized value in the regulatory guidelines and means a dose of 90% to the prostate. Anything outside of the D90 value is considered to be a medical event.) The licensee performed a comprehensive review of all 44 prostate implants performed since August 2003. The licensee's five medical events include one overdose to the prostate and four underdoses to the prostate. All were patients who received seed implants only. No medical events were identified involving doses to other organs or tissue above 0.50 Sv and 50% more than the expected dose. The licensee has notified the referring physicians and will not be notifying the affected patients per DHS 157.72(1)(e). Overdoses (medical event criteria used: D90>195 Gy): 11/13/2008: 199.15 Gy Underdoses (medical event criteria used: D90<135 Gy): 2/9/2007: 100.20 Gy; 11/12/2007: 127.34 Gy; 6/16/2008: 130.12 Gy; and 7/13/2010: 116.16 Gy
This is an update to Event Notification 46528. The licensee recently performed post-implant dosimetry on seven prostate brachytherapy patients whose post-implant dosimetry had never been performed. Evaluation of these seven implants prompted the licensee to report two additional medical events. The medical events involved permanent implants of l-125 for prostate brachytherapy where the total dose delivered to the prostate differs from the prescribed dose by 20% or more. The licensee is in the process of notifying the affected patients and referring physicians. Underdoses (medical event criteria used: D90<135 Gy): 8/22/2005: 102.89 Gy; and 5/8/2006: 126.24 Gy; DHS will send a special inspection team to determine the root cause(s) of these medical events. WI Event Report ID No.: WI 110001 Update Notified FSME(Angela McIntire) and R3DO (Richard Skokowski) 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.
This is a second update to Event Notification 46528. The licensee is retracting an overdose previously reported for a patient who received a permanent prostate implant on November 13, 2008. During a reactive inspection conducted on February 18, 2011, DHS inspectors identified that post-implant dosimetry of prostate brachytherapy implants had not been performed appropriately. Specifically, the licensee's former physics consultant generated post-plans that were not based on the number of I-125 seeds actually implanted in the patients. For the patient in question, the original post-plan was based on an implant of 98 seeds; however, only 76 seeds were actually implanted. The licensee's current physicist generated a new post-plan using the correct number of I-125 seeds and observed a corresponding reduction in dose delivered. The new D90 value for this patient does not meet the licensee's medical event criteria. WI Event Report ID No.: WI 110002, 2nd Update Notified FSME(McIntosh) and R3DO (Dickson) |
| ENS 46529 | 10 January 2011 14:29:00 | The following information was received from the State of Wisconsin via fax: On January 10, 2011, the licensee's Radiation Safety Officer reported the identification of ten medical events involving permanent implants of I-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. During a recent routine inspection, Department of Health Services inspectors determined that the licensee was not reviewing prostate brachytherapy cases against medical event criteria. The licensee is identifying as a medical event any case where D90<135 Gy or D90>195 Gy for patients who receive seed implants only, and D90<100 Gy or D90>145 Gy for patients who receive seed implants in conjunction with external beam therapy (combined therapy). The licensee performed a comprehensive review of all 82 prostate implants performed since August 2003. The licensee's ten medical events include six overdoses to the prostate and four underdoses to the prostate. No medical events were identified involving doses to other organs or tissue above 0.50 Sv and 50% more than the expected dose. The licensee has notified the referring physicians and will not be notifying the affected patients per DHS 157.72(1). Overdoses (medical event criteria used - D90>195 Gy): 12/23/2003: 204.95 Gy; 10/27/2004: 160.49 Gy (combined therapy, medical event criteria used - D90>145 Gy); 1/20/2006: 211.23 Gy; 6/14/2006: 207.03 Gy; 9/5/2007: 205.7 Gy; and 10/17/2007: 210.47 Gy. Underdoses (medical event criteria used - D90<135 Gy): 9/26/2003: 123.03 Gy; 10/31/2003: 116.78 Gy; 1/14/2004: 126.73 Gy; and 3/31/2009: 123.74 Gy. DHS will send a special inspection team to determine the root cause(s) of these medical events on February 2, 2011.
This is an update to Event Notification 46529. On January 31, 2011, the licensee retracted one medical event for a prostate brachytherapy patient treated on 3/31/2009 based on refined post-implant dosimetry. Further updates will be made through NMED. DHS will send a special inspection team on February 3 2011. " WI Event Report ID No.: WI 110001 Update Notified FSME(Angela McIntire) and R3DO (Richard Skokowski) 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 46249 | 14 September 2010 12:57:00 | The following information was received by facsimile: On September 14, 2010, the Department (Wisconsin Department of Health Services) received a facsimile from the licensee's Radiation Safety Officer (RSO) that a medical event occurred on September 9, 2010, involving a permanent implant of I-125 seeds for a prostate manual brachytherapy procedure where the total dose delivered differs from the prescribed dose by 20% or more. This is a medical event as described in DHS 157.72(1)(a)1. The prescribed dose was 145 Gy; the dose delivered was 80 Gy. The licensee uses D80 < 80% as their dose based criteria for determining medical events. Using the licensee's dose based criteria of D80 < 80% the dose received by the prostate was 55% of the intended dose. The underdose was identified during the post-implant planning for the procedure. The RSO indicated that the possible cause was the maximum insertion depth was 0.6 cm below the base of the prostate gland and all needles were implanted distal to the base resulting in the area being 'cold'. Possible corrective actions are under review by the licensee's staff and a one month post-implant CT is planned to determine the impact to the patient. (Department) inspectors will investigate this medical event on September 16, 2010. Wisconsin Event Report: WI100015 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 45222 | 22 July 2009 16:29:00 | The following is a summary of information received via fax from the State of Wisconsin. For more details contact the Headquarters Operations Officer. On July 16, 2009, DHS (Department of Health Services) performed a reciprocity inspection at Wheaton Franciscan Healthcare - All Saints for a source exchange of a 10 Ci, Ir-192 source and routine maintenance of a Nucletron Micro Selectron HDR (High Dose Rate) classic remote afterloader brachytherapy device. During the inspection, three items were identified during testing of the HDR unit: 1) HDR control panel did not operate as designed; 2) the HDR/Linac switch was not wired correctly; and 3) Radiation area monitor was operating sporadically. On July 16, 2009, DHS informed the licensee that they would not be able to use the HDR unit for patient treatments until all areas of concerns were corrected. The licensee informed DHS that the HDR unit has NOT been used for any patient treatments since the Department authorized the licensee the HDR unit on August 8, 2008. On July 21, 2009, DHS issued the licensee a Confirmatory Action Letter effective July 17, 2009, that the licensee is not allowed to use the HDR unit for patient treatments until the listed items were corrected The licensee has committed to address all equipment malfunctions prior to treating patients using the Nucleation HDR unit. DHS plans to conduct an inspection prior to patient treatment. The State does not anticipate any media attention. |
| ENS 44398 | 8 August 2008 13:38:00 | Material received at scrap yard on August 5, 2008. Wisconsin DHS verified via phone that material was locked in a secure location from members of the public. On August 7, 2008 DHS investigated the radioactive material, a compacted 55 gallon drum with multiple pieces of scrap inside drum. A mini-spec GR-135DN was used to determine the source of radiation as Ra-226. Radiation exposure and contamination surveys were conducted on the outside of the compacted drum. The maximum exposure observed was 500 uRem/hr. The contamination survey on the drum found no contamination. DHS staff tried to locate the source of radiation inside the drum where the highest radiation levels were located. During the attempt, several pieces of scrap were removed and surveyed and no radiation above background except for one piece that read above background. Material was properly tagged and bagged. The staffs gloved hands were frisked and contamination was present. Individual doffed gloves and re-performed hand frisk and no contamination was found. The staff halted any further handling activities at this time to prevent any possible spread of contamination. The material was properly tagged, bagged and stored at the scrap yard in a locked holding area that is not accessible by members of the public. DHS is exploring options to properly dispose of this radioactive material. State Event Report: WI080008 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. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source |