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| Entered date | Event description | |
|---|---|---|
| ENS 56782 | 9 October 2023 14:32:00 | The following information was provided by the New Hampshire Radiological Health Section (NHRHS) via email: Via telephone on October 9, 2023, the licensee's Radiation Safety Officer reported a medical event associated with use of their Varian BRAVOS high dose rate remote afterloader (HDR). During a treatment fraction administered on October 5, 2023, a patient received a dose of 435 centigray (cGy) (435 rad) versus a planned dose of 700 cGy (700 rad) to the target organ (the cervix) and an estimated 586 cGy (586 rad) versus an expected 300 cGy (300 rad) to the rectum (a non-targeted organ). The dose to the non-target organ exceeds 50 percent of the expected value had the procedure been given in accordance with the written directive. The preliminary findings indicate the wrong HDR channel had been selected. The patient and physician were notified. No health effects are anticipated as a consequence of this event. When the treatment fractions are completed, the target organ will have received a dose within 20 percent of the written directive. The patient and the patient's physician were advised. No negative health effects are anticipated. Treatment fractions will continue to ensure the desired dose to the target area will be provided. The investigation, with possible identification of further corrective actions, is ongoing. More information is anticipated within 15 days. Medical Event: Exposure to a non-target organ exceeding 50 percent of anticipated during a fractional treatment. Dose intended to target organ planned / actual: 700 cGy (700 rad) / 435 cGy (435 rad); 62 percent of planned. Dose to non-target organ anticipated / actual: 300 cGy (300 rad) / 586 cGy (586 rad); 95 percent greater than anticipated. NMED Report Number: NH-23-0002 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 56657 | 4 August 2023 14:32:00 | The following information was provided by the New Hampshire Radiological Health Section (NHRHS) via email: On August 2, 2023, Nylon Corporation of America (NYCOA) reported that a specifically-licensed fixed level gauge (Berthold, Serial No. 175-02-07) installed on the `Capro Recovery Unit' apparently failed a semi-annual detector test. The detector provides a remote indication of tank level and shutter position. In the absence of remote indication, shutter position can be noted visually. The gauge shutter is manually operated and performs as designed. Additional testing performed on August 3, 2023, verified the detector failure. NYCOA formally reported their findings to the NHRHS via email on August 3, 2023 at 1316 (EDT). The fixed gauge (Berthold Model LB-300L) houses a 32.9 MBq (0.89 mCi) Co-60 source assayed on January 1, 2006. The current activity is calculated as 3.3 MBq (0.088 mCi). The gauge is affixed to a tank that is suspended about 9 feet above the process room floor. The location cannot be accessed without a ladder. The surrounding area contains process piping and is not normally occupied. On August 4, 2023, at 0930, NHRHS inspectors arrived to perform a reactive inspection. As found, the level gauge shutter was closed and appropriately locked-out/tagged-out of service. The highest measured exposure rate was 0.327 mR/hour in contact with the gauge housing (shutter closed). At head height, below the gauge, the exposure rate was 0.010 mR/hr, which approximates normal background. A Ludlum 9DP ion chamber was utilized for these measurements. There is no indication of personnel overexposure. NYCOA stated that the Capro Recovery Unit has been offline for about five years and there are no near-term plans to bring it back online. NYCOA will investigate removal and disposal of the level gauge rather than repair the detector. NMED Report Number: NH-23-0001 |
| ENS 53787 | 11 December 2018 16:18:00 | The following was received from the State of New Hampshire via email: On December 11, 2018, the NH Radiological Health Section (Agency) was notified by the Radiation Safety Officer at Lakes Region General Hospital of the administration of an incorrect radiopharmaceutical. On this date a patient received an injection of 7.7 milliCuries (mCi) of technicium-99m Sestamibi rather than 7.7 mCi technicium-99m Choletec. The consequence is a dose to an unintended organ. The patient, radiologist, and authorized providers were informed. No health effects are anticipated. The RSO will conduct a root cause analysis and present a written report of the findings and corrective actions to the Agency within 15 days. New Hampshire Event Report ID No.: NH 18-005 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 55179 | 7 April 2021 13:49:00 | The following was received from the New Hampshire Radiological Health Section via email: (In January 2018), during routine semi-annual leak testing of a generally licensed fill-level gauge, it was discovered that the gauge shutter would not close completely by ordinary means and the red 'Source ON' status indicator lamp remained continuously lit. A manual shutter handle within the actuation assembly was used to close the shutter. While doing so, a green wire was noted as brushing against the shutter linkage and impeding its operation. The gauge was already out of service for maintenance, and remained so until the shutter mechanism was repaired. No personnel exposure. The cause was determined by the service technician as a wire interfering with the path of the shutter linkage, preventing full closer of the shutter. The wire was moved out of the way, allowing the shutter to move along its full path as designed. Gauge Details: Americium-241, 300mCi (11.1 GBq) sealed source; Industrial Dynamics Model 19567; s/n 156LX; no detectable leakage The New Hampshire Radiological Health Section considers this event closed. Report ID #: #NH18-0001 |
| ENS 55178 | 7 April 2021 13:49:00 | The following was received from the New Hampshire Radiological Health Section via email: (In April 2017), a generally-licensed static eliminator was lost during a routine replacement of a series of 30 static eliminators. The devices are leased from NRD Corporation and are affixed to assembly line machines. Annually, they are removed from service and returned to NRD Corporation. The missing device was last in use during a production run on 3/10/17 between 1500 EDT and 2400 EDT. Device exchange occurred during the 2nd shift after the line was shut down. The missing device was noticed during the subsequent 1st shift when supervision performed accountability. A facility search and employee interviews were conducted. Roll-off containers servicing the 'household' and 'recyclables' waste streams were searched without success, likely because the roll-offs contained a significant amount of waste that impeded the search for the relatively small device. The device was still missing after 30 days. The licensee concluded the device was inadvertently disposed in the 'household' waste stream, which is taken to a waste-to-energy incinerator. Device Details: Polonium-210, 10 mCi (0.37 GBq); NRD Corporation, Model P-2021-8000 static eliminator, s/n A2KN339 The New Hampshire Radiological Health Section considers this event closed. Report ID #: #NH17-0004 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 55177 | 7 April 2021 13:49:00 | The following was received from the New Hampshire Radiological Health Section via email: (In January 2017), during routine maintenance of a generally licensed fill-level gauge, it was discovered that the gauge shutter would not close by ordinary means. A manual shutter handle within the actuation assembly was used to attempt to close the shutter, but the linkage was binding and causing the shutter to remain open. The gauge was already out of service for maintenance, and remained so until the shutter mechanism was repaired. No personnel exposure resulted. The cause was determined by the service technician as a binding solenoid spool. The spool bushing was reamed out and the shutter linkage was lubricated, which allowed the solenoid spool to resume moving freely as designed. Gauge Details: Americium-241, 300mCi (11.1 GBq) sealed source; Industrial Dynamics Model 19567; s/n 156LX; no detectable leakage The New Hampshire Radiological Health Section considers this event closed. Report ID #: #NH17-0003 |