Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 54819 | 6 August 2020 10:33:00 | The following is a summary of information received via email: On 3/27/20, the Vermont Department of Health (VDH) was notified that a waste transport truck was rejected at a waste facility in Concord, NH. The truck was rejected because radioactive material was detected in the waste. The truck was redirected to Goodenough Rubbish Removal in Brattleboro, VT, and instructed to isolate the waste. On 3/30/20, VDH Radiation Control responded to the waste center. The radioactive waste was identified as clay cat litter containing I-131 with a maximum dose rate of 8.04 mrem/hr on contact and 0.54 mrem/hr at one meter while background measurements were 10 microR/hr. The waste hauler was instructed to isolate the container in a remote section of the recycling center with the contents covered for 80 days. On 4/3/20, VDH issued Vermont Information Notice IN 20-001 (Release of humans and animals receiving I-131 therapy) to all Vermont radioactive materials licensees who are authorized to use I-131. This Information Notice recommends all affected licensees review their I-131 administration procedures, patient release criteria, and pet owner release instructions. On 6/26/20, a VDH inspector returned to survey the material, and found that the radiation levels of the material were indistinguishable from background. With the decay of the I-131 waste this incident has been closed out by VDH on 8/5/20. Vermont Incident No.: VT-20-002 |
| ENS 54818 | 5 August 2020 17:17:00 | The following is a summary of information received via email: On 2/27/20, the Vermont Department of Health (VDH) was notified that a waste transport truck was rejected at a waste facility in Hudson Falls, NY. The truck was rejected because radioactive material was detected measuring 1.4 mrem/hr while background radiation was 0.01 mrem/hr. The truck was redirected to Tam Recycling in Pownal, VT, and instructed to isolate the waste. On 3/2/20, the Vermont Hazardous Materials Response Team (VHMRT) and a member of VDH Radiation Control responded to the recycling center. The radioactive waste was identified as human bladder control products which contained an estimated 4.6 microCi of I-131. The contents were double bagged and isolated in a remote storage area at the recycling center for to decay. On 4/3/20, VDH issued Vermont Information Notice IN 20-001 (Release of humans and animals receiving I-131 therapy) to all Vermont radioactive materials licensees who are authorized to use I-131. This Information Notice recommends all affected licensees review their I-131 administration procedures, patient release criteria, and pet owner release instructions. On 6/26/20, a VDH inspector returned to survey the material, and found that the radiation levels of the material were indistinguishable from background. With the decay of the I-131 waste this incident has been closed out by VDH on 8/5/20. Vermont Incident No.: VT-20-001 |
| ENS 54468 | 9 January 2020 07:33:00 | The following is a synopsis of a report from the Vermont (VT) Department of Health (the Department): On November 27, 2019, a prostate seed implant (PSI) procedure using Iodine-125 (I-125) seeds was performed. During the latter part of the procedure, while loading one last, extra needle for the radiation oncologist (the Authorized User), the authorized medical physicist (AMP) lost control of one I-125 seed. A number of surveys were conducted immediately following the loss of the seed, producing only background readings. On December 4, 2019, a Department Senior Radiological Health Specialist conducted a follow-up survey in the PSI procedure room and waste storage areas. The lost seed was not located. As a corrective action, the licensee may consider ordering additional seeds in the form of preloaded needles to avoid handling individual prostate seeds. The lost prostate seed is believed to have fallen into the bore of the implanting needle and was subsequently implanted into the prostate. This is not believed to have any clinical significance on the resulting absorbed dose to the prostate, urethra, or rectum. The patient had 76 prostate seeds planned to be implanted and a single extra seed would result in approximately 1 percent additional absorbed dose to the treatment volume. As verification, a post-implant treatment plan was calculated with an extra prostate seed placed near the location of the last needle within the treatment volume. The resulting dose metrics confirmed that absorbed doses increased by about 1 percent. The potential radiation exposure to an individual that is continuously present near the lost seed was evaluated and determined to be less than the 0.1 rem annual public exposure limit. No personnel contamination occurred as a result of this event. VT Incident Number: VT19-002 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 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 54408 | 20 November 2019 15:48:00 | The following report was received from the Vermont Department of Health via email: Medical Event: Y90 resin Sir-Spheres treatment infusion aborted due to kinked microcatheter. 99.5 (percent) of the drawn dose was not delivered to the treatment site. Contamination of IR (interventional radiology) suite floor detected. Contamination of infusion paraphernalia (gloves, shoe covers, gauze, towels) detected. Contaminated items were contained and floor was decontaminated to acceptable levels by RSO (Radiation Safety Officer). Date of Event: 11/18/2019 11/18/19 AU (Authorized User) notified referring physician and patient of the medical event 11/19/19 RSO contacted State of Vermont 11/19/19 NRC contacted for clarification of event 11/20/19 RSO contacted Sirtex Incident Details: Terumo Progreat, I.D. 0.027(inches) (0.7mm), 130cm length, was used initially to access treatment site. Boston Scientific, I.D. 0.021(inches) (0.5mm), 130cm length, was used to access treatment site after unsuccessful attempt with Progreat. IR (Interventional Radiologist) Fellow assembled the delivery device. The original dose measurement was 2.2 mR/hr at 1230 (EST). The Nalgene with undelivered dose vial and the second Nalgene with delivery catheter were measured in exactly the same setup as original dose measurement. The total residual in the 2 Nalgene containers were 1.9 mR/hr + 0.25 mR/hr = 2.15 mR/hr at 1430. With 2 hours decay correction, the Nalgene containers reading should be 2.15 x 1.02 = 2.19 mR/hr. 2.19 / 2.2 = 0.995 or 99.5 (percent) for Vial + Catheter. Therefore, about 0.5 (percent) of the drawn dose (44.3 mCi) was lost. 0.5 (percent) of 44.3 mCi is 0.2 mCi (This is the calculated amount of Y90 lost) The DAVYR (Dosimetry and Activity Visualizer for Y-90 Radioembolization) application provides the following liver dose calculation based on the partition model: Liver = 27.5 Gy for a 1.5 GBq (or 40.5 mCi) dose delivery. This is based on 100 (percent) of prescribed dose being delivered. In the worst-case scenario where all the lost activity (0.2 mCi) was delivered to the patient, the liver dose calculation is: Liver = 27.5 Gy x (0.2 mCi / 40.5 mCi) = 0.14 Gy (or 14 rem) The only way to properly measure the bags of contaminated paraphernalia (towels, gloves, gauze, shoe covers) in the same setup as the original dose measurement would involve transferring the contents into several Nalgene containers. This can be done next day to properly account for lost Y90 activity. Medical event criteria - the byproduct material administration has to meet the following (10 CFR 35.3045): 1. The dose differs from a dose that would have resulted from the prescribed dosage by more than 50 rem to an organ or tissue. The unintended dose to any organ or tissue from the lost 0.2 mCi Y90 would be similar to the Liver dose calculated above (14 rem) and does not exceed 50 rem difference. Note: The highest delivered dose to Liver from the lost Y90 is calculated to be 14 rem. This is below the target dose of 110 Gy (or 11,000 rem) and does exceed the 50 rem difference; however, this was a medical safety decision resulting from unforeseen microcatheter kinking due to patient anatomy. 2. The total dose delivered differs from the prescribed dose by 20 (percent) or more. Yes, the total dose delivered is calculated to be about 0.2 mCi and is much below the prescribed dose of 40.5 mCi. A medical safety decision to abort the infusion was due to an unforeseen device event (kinked microcatheter) that prevented the safe delivery of Y90 microspheres.
The following update was received from the Vermont Department of Health via email: As a follow up to Event Number 54408, Y-90 Sirsphere event, the calculated dose to the unintended organ, the pancreas, is 14 Rem or 0.14 Gray. Notified R1DO (Henrion) and NMSS Events Notification via email. 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. |