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| Entered date | Event description | |
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| ENS 55209 | 23 April 2021 08:38:00 | The following was received via email from the State of Georgia. (The licensee) called and reported a gauge stolen off the back of one of their work trucks on April 22, 2021. The technician responsible for the gauge was working on the Augusta Airport project. The gauge was left locked and chained in the back of his truck in the motel parking lot overnight. The technician last saw the gauge at 1900 EDT on April 21, 2021. When (the technician) went to the truck (on April 22, 2021) the chain and lock had been cut and the gauge removed. The local Sheriff has been informed and the case number is 21-112409. This has been assigned and more information is forthcoming. Troxler Model Number: 3400 Serial Number: 22667 Activity: Cs-137 (10mCi); Am-241/Be (40 mCi) Georgia Radioactive Materials Program NMED Report Incident # 40 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 55089 | 29 January 2021 12:05:00 | The following was received from the Georgia Environmental Protection Division (EPD) via email: Pilgrim's owned and operated three gas chromatographs (GC) units (were in a) poultry feed laboratory in Gainesville, Georgia, pursuant to general license #GA1786-2017-G1-1. This letter is intended to provide notice as required by Ga Comp. R. & Regs. �� 391-3-17-.02(6)(c)(3)(vii)(II) and 391-3-17-.02(6)(c)(3)(xi) that these three GC units were inadvertently disposed of in the Richland Creek Landfill, owned and operated by Republic Services, Inc. (Republic) in Buford, Georgia. At the direction of Georgia EPD, Pilgrim's is in the process of coordinating with Republic to develop a plan for addressing this inadvertent disposal. That plan will be submitted to EPD for approval as part of a Corrective Action Plan. For background, early on the morning of December 29, 2020, Pilgrim's (was) advised that a Republic waste collection truck serviced Pilgrim's municipal solid waste (MSW) container located in Gainesville, Georgia at its poultry feed laboratory. Later that morning, Pilgrim's realized that the three gas chromatography instruments, destined for shipment back to the licensed manufacturer of these radiological materials, were inadvertently moved from the warehouse and placed into a MSW dumpster. Pilgrim's immediately notified Republic of the discovery at approximately 1140 EST. Pilgrim's (was) advised that Republic immediately shifted disposal operations at its landfill away from the area of disposal and flagged off the area of disposal for that day to keep operators out and to prevent additional disposal operations. As part of the initial discovery, Pilgrim's confirmed via security video camera footage that the equipment was placed in the dumpster designated for MSW only. Republic confirmed that the truck did arrive at Richland Creek Landfill for disposal. Safety Data Sheets (SDSs) for the gas chromatography instruments were provided to Republic. The SDS indicates that the three instruments contained a small integral component with 15 millicuries (mCi) Nickel-63 (Ni-63), a low-energy beta-emitting radioactive isotope. Based on information describing the gas chromatograph instruments provided by the manufacture, it is understood that that the Ni-63 components are enclosed in a stainless-steel housing as part of the instruments' electron capture detectors (ECD's). Each one of the Ni-63 components, enclosed within the stainless-steel housing, are approximately 1-2 inches wide and 2-3 inches tall. The Ni-63 incorporated into the ECDs is a solid-state material, not a liquid, with very low potential of leakage. Republic and EPD's Solid Waste Management Unit were notified of the inadvertent disposal on December 29, 2020. Currently, Pilgrim's is coordinating with Republic to develop a plan to address final disposition of the licensed equipment. This plan will be submitted as a Corrective Action Plan for EPD's approval. 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 54974 | 30 October 2020 15:34:00 | The following was received from Georgia Radioactive Materials Program (GA RMP) via email: On Oct 30, 2020, (GA RMP) received an email, from the Assistant RSO (Radiation Safety Officer, Emory University), informing (GA RMP) that a second Y-90 TheraSpheres event occurred on Oct 29, 2020. A patient was administered with 16.2 mCi of Y-90 TheraSpheres using a high flow microcatheter and a larger syringe. The product representative from Boston Scientific was there to consult with the authorized users and technologist prior to treatment. Once it appeared that the micro catheter and Y-90 line and vial were in proper positioning, the Y-90 was administered. Subsequently, the line was flushed three times using approximately 50-60 ml of saline. After the procedure, all items were surveyed and calculated that only 7.3 mCi of Y-90 was administered. Since all waste was surveyed as a whole and not independently from each item, the Assistant RSO did not have the information to discern whether residual Y-90 remained in each product (micro-catheter, line, and vial). Until they can determine the causes of the misadministration, Emory has halted TheraSpheres administration at Emory at Midtown, and substituted Y-90 Sirspheres where they can. Emory University Hospital also uses TheraSpheres, but has not reported any problems. Emory investigation is ongoing. (GA RMP) will provide follow-up information as it is obtained. Georgia Incident No: 32 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 54967 | 27 October 2020 17:50:00 | The following was received from the Georgia Radioactive Materials Program (the Program) via email: The Y-90 event (occurred) on October 23, 2020. The AU ((Authorized User)) notified the Assistant RSO ((Radiation Safety Officer)) on October 26 and then subsequently notified our Program on October 27, 2020. The reason for the delay notifying the Program was both the Radiation Safety Officer (RSO) and Assistant Radiation Safety Officer (ARSO) were furloughed on Friday ((October 23)) and they did not check their emails until Monday. They used Monday to gather information before contacting the State Program. The patient was administered with 1.58 GBq using a 10 mL syringe. The reason for the 10 mL syringe was a small gauge catheter was used. The line was subsequently flushed 3 times with saline solution to ensure the Y-90 was pushed through. After the procedure, the catheter was removed and surveyed along with the vial to determine residual activity. It was calculated that there was more residual (activity) than expected. Though it is has not been clearly determined the cause of the excess residual (activity), it is thought to be either not enough saline was used to push the Y-90 through or it got stuck in the catheter. The ARSO and the Authorized User will discuss the cause of the event, best way to prevent occurrence, and (perform) patient follow-up. The licensee will follow-up with a report within 15 days. In the interim, the licensee is required to submit a copy of the written directive, Y-90 procedure and checklist, and the rational why they used a small catheter gauge. The actual dose delivered was 1.039 GBq (65.5 percent). Georgia Incident No: 31 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 54882 | 4 September 2020 15:01:00 | The following was received from the Georgia Radioactive Materials Program via email: At the end of the administration of Y-90 SIR Spheres (for the treatment of tumors in the right lobe of the liver), the delivery vial (D-Vial) appeared to overfill as the radiologist was attempting to mix the spheres with a 50/50 solution of contrast and 5 percent dextrose/glucose (D5W). The radiologist noticed some clumping and after attempting to gently disperse the Spheres, he gave a couple hard pushes of the contrast/D5W into the D-Vial. At that time, he noticed the leak. He examined the septum and found it to be dry. As a precaution the radiologist put Durabond on top of the septum. Further examination showed that the material leaked out of the sides of the crimped vial top rather than the septum. The procedure was stopped to prevent further contamination. The event occurred while using SIRTEX new SIROS delivery system. The SIRTEX representative was present providing guidance to the radiologist as this was the first time he used the new system. It is estimated that 75 percent of Y-90 SIR-Spheres were administered to the patient (Prescribed Activity: 3.1 GBq (83.7 mCi); Delivered Activity (estimated): 2.87 Gbq (77.7 mCi)). It is likely that the residual activity was over estimated due to contamination of the SIROS delivery dome. The usual waste from the procedure is contained in a 1-liter Nalgene containers and then placed in a Lucite shield for dose rate measurements to determine the residual activity. The Siros delivery dome could not be measured in the same geometry and likely resulted in an increased dose rate and underestimate of the total dose delivered. At this time, the prescribing physician indicated he does not expect any adverse effects for the patient and is awaiting the dosimetry evaluation from the patients PET/CT Scan. Attempts have been made to recreate the event without success. There is speculation regarding the size of the dose and that the number of Spheres may have been a factor (larger than typically administered). Representatives from SIRTEX indicate that this has not been an issue at other sites. Prior and subsequent studies with the new SIROS delivery system were successful with less activity. Further evaluation of the equipment to determine why the vial leaked, will be performed following decay and return the manufacturer. Georgia Incident Number: 30 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 54441 | 13 December 2019 10:17:00 | The following report was received from the Georgia radioactive materials program environmental protection division via email: Augusta University Medical Center had an incident yesterday (December 5, 2019) in the Interventional Radiology (IR) Suite during a Y-90 TheraSphere procedure. The Y-90 TheraSphere delivery was performed in the usual fashion, per TheraSphere protocol, with 3 flushes of the administration vial. Both delivery and nuclear medicine pre-procedure preparation was performed per standard radiopharmaceutical (TheraSphere) protocol. During administration, the remaining undelivered dose became stuck/trapped in the transport vial and could not be administered. About 40 percent of the prescribed radiation dose was delivered to the patient, which is less than the criteria in Rule 391-3-17-.05.(115)a.1(i), which states, 'The total dose delivered differs from the prescribed dose by 20 percent or more.' A small amount of the Y-90 microspheres spilled onto the administration table, which was covered with absorbent towels. Augusta University staff isolated the contamination, scanned all IR Suite staff to ensure the contamination was not spread outside the immediate area, and called for assistance with clean-up. All contamination was located and cleaned-up, and all swipes have been counted and the results show no residual contamination in the suite or on any equipment in the suite. All radioactive material has been collected and is being stored and managed as radioactive waste. A formal written notification to your office will be submitted within 15 days of the event. This formal written notification will include all of the information required by Rule 391-3-17-.05.(115). Georgia Incident No.: 22 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 54334 | 16 October 2019 17:20:00 | EN Revision Text: CONTAMINATINON OF HOT LAB DUE TO BREAKING CAPSULE The following report was received from the Georgia Radioactive Materials Program via email: A patient diagnosed with hyperthyroidism was scheduled to receive 30 mCi of Iodine-131 on Oct 15, 2019. The patient informed the AU (authorized user) that they could not swallow the capsule, so the AU proceeded to break the capsule in half and pour the contents in water to easily administer to the patient. The patient and AU were in the treatment room when the AU began to break the capsule. The AU then went to the hot lab where he successfully broke the capsule using a syringe needle. The nuclear technician inquired as to what was happening in the hot lab and realized that there may be a potential contamination issue and contacted the RSO (Radiation Safety Officer). The areas were surveyed and determined to be contaminated with Iodine-131 was the hot lab, hallway in front of the hot lab, counter of the treatment room, scrub pants, shoes and socks. The RSO took the scrub pants and sock and shoes and placed them in an area for DIS (decay in storage). He proceeded to clean the area from least contaminated, the hallway and treatment room, but could not get it completely clean. The treatment room is a less used room and isolated so that room could be sealed off and secured. The hallway is posted and cordon off. Currently, the RSO is uncertain as to how much contamination is in the hot lab and has the room sealed and secured until he can further assess the area. The staff who were working in the area consisted of the RSO, Assistant RSO, nuclear technician, and AU were monitored for thyroid uptake. Results were negative. The patient was not monitored for thyroid uptake since the patient was sitting at the opposite side of the treatment room opposite of where the contamination occurred. The floor of the room and adjacent hallway was free of contamination. In addition, the patient had a Iodine-123 uptake one week prior. So they would have had some residual Iodine-123 still in the body. The patient was never administered the Iodine-131 in water. The RSO will prepare a full report discussing the incident, root cause and correction plan within 15 days. An associate will be assigned to the event.
The following is a synopsis of a report received from the Georgia Radioactive Materials Program via email: On October 30, 2019 a reactive inspection was performed by the Georgia Radioactive Materials Program. The areas of contamination were verified to have a physical barrier to prevent inadvertent entry and signs posted to warn individuals of the contaminated areas. The Grady Memorial Hospital Radiation Safety officer (RSO) stated that the lab will not re-open until the contamination level reaches background, approximately 80 days from the time of the incident. The RSO temporarily removed the authorized user from administrating any therapeutic doses indefinitely. The RSO reported that there will be proper training for authorized users, technologists and residents who are involved in administering radioactive materials. A technologist will be required to be present in the room where I-131 is administered. Instructions will be added about not opening or breaking capsules containing radioactive materials to hospital procedures and refresher training will encompass the procedures. The physician did not think a bioassay was necessary for the patient as they were not exposed. Notified the R1DO (Henrion) and NMSS via email. |
| ENS 54195 | 2 August 2019 15:49:00 | We received the following notification via email from the Georgia Environmental Protection Division: On August 2, 2019, our program (Georgia Environmental Protection Division) received a call from (the licensee) RSO, reporting a fire in a building at their facility that stored 6 radioactive sources. The fire occurred on August 1, 2019, is believed to have been caused by an electrical fire which resulted the building to burn to the ground. The licensee searched the area, which is approximately 8'X10', in hopes to recover the sources. Only 2 of the 6 sources were recovered. However, the 2 sources are unidentifiable. The 2 sources are currently stored in a bag in a secured building. They are assuming the 4 sources were burned in the fire. The licensee did a general survey of the area but were only able to detect microrem readings. Until the area has been determined free of contamination, the area will remain secured. The licensee will collect sample debris and wipe samples to determine if there is any contamination in the area. The samples will be sent off for analysis. The Fire Department will not be able to enter the area to determine the cause of the fire until the area is considered free from contamination. The licensee will be sending a follow-up report describing the incident, a current inventory of the sources damaged/lost, and current plan to determine the extent of the contamination and disposition of the sources. THIS MATERIAL EVENT CONTAINS A "NOT RECORDED" LEVEL OF RADIOACTIVE MATERIAL |
| ENS 54165 | 16 July 2019 13:34:00 | EN Revision Text: AGREEMENT STATE REPORT - GAUGE SHUTTER MALFUNCTIONED The following information was obtained from the state of Georgia via email: The shutter on a saltcake density meter was identified as needing attention on the last inventory and Berthold was scheduled to come on the next outage to repair or replace as needed. The outage is scheduled for 7/31/19. Today, (the licensee) identified that a saltcake pump near the gauge needs to be replaced and the gauge is listed on the pump's lockout sheet. When IM (instrument maintenance) attempted to lock out the meter as part of the established lock out, the shutter handle broke meaning the gauge cannot be locked out. (Lock out requires all energy sources affecting the pump to be locked out. The gauge is in the line ahead of the pump and about 6 feet away so does not really affect the pump.) Radiation survey at the pump showed 65 microRem/hr radiation. (500 microRem/hr at gauge surface and 134 microRem/hr at one foot) Maintenance work at the pump will continue with a lock out variance to cite not being able to close the shutter and a proximity radiation work permit used. Berthold is still scheduled to come in 7/31/19 for gauge shutter repair. Source is Cesium-137, 20 mCi, model P-2623-100 in LB7440 holder, serial no. 2104-6-90.
The radioactive material was transferred to Berthold for disposal on 11/25/19. Notified R1DO (Henrion) and NMSS_EVENTS_NOTIFICATION (via e-mail). |
| ENS 53996 | 12 April 2019 13:21:00 | The following is a synopsis of the information received from the Radioactive Materials Program of Georgia received via email: On April 3, 2019, an underdose of Y-90 TheraSpheres was administered to a patient. Only 65% of the prescribed dose was administered. On April 5, 2019, the remainder of the prescribed dose was delivered to the patient. There is no definitive cause identified at this time but the licensee has concluded that it was probably a delivery equipment problem (perhaps with the tubing). The licensee will follow-up with a formal report.
The state of Georgia amended the original report to state that the deliver apparatus is awaiting decay to background and will be examined locally or will be sent to the manufacturer for a root cause analysis. The prescribed dose was 127 Gy. The delivered dose was 59.8 Gy which is 47% of prescribed dose. As stated above, the patient was informed and returned two days later to complete the treatment. NMED Item: 190182 Notified R1DO (Schroeder) and NMSS Events Notification (email).
The state of Georgia has amended the original report and the update from 4/29/20 as follows: -the prescribed dose was 122 Gy -the delivered dose was 78.8 Gy -the difference is 64.5 percent. This same event was also reported under NRC Event Notification #54010 which has been deleted from the report database. Notified R1DO (Schroeder) and NMSS Events Notification (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. |
| ENS 53951 | 21 March 2019 15:44:00 | The following was received from the state of George via e-mail: On January 17, 2019, GE Healthcare in Atlanta (GA 1166-1) consigned a Mo-99/Tc-99m generator (5.14 mCi at the time of shipment) to (common carrier) for delivery to Medi-Ray in Tuckahoe, NY for recycling (the trip included a transit stop in Charlotte, NC). As of March 20, 2019, the device has not arrived at its final destination. On March 18, 2019, (the common carrier) formally notified GE Healthcare that the device was lost in transit. This information was received on March 20, 2019. 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 53468 | 22 June 2018 14:26:00 | EN Revision Text: AGREEMENT STATE REPORT - DOSE MISADMINISTRATION The following information was received from the State of Georgia via email; RMP (Georgia Radioactive Materials Program) received a call regarding an event that occurred at the main Emory Campus. A 57 year old male was treated on June 21, 2018 with 81.1 mCi of Y-90 Therasphere. The treatment site was the right lobe of the liver. Approximately an hour after the treatment the patient was scanned. The scan indicated that approximately 80% of the administered dose went to the left lobe, 10% went to the right lobe and some went to the stomach and some went to the 1st portion of the duodenum. It was determined there was a vessel spasm during the treatment that caused the theraspheres to shunt to the left lobe of the liver. 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. Georgia Incident Report # 3.
The following information was received from the State of Georgia via email: (The Georgia Radioactive Materials Program) received Emory's report regarding the Y-90 procedure and verified the backflow to the left lobe was due to shunting. Based on this information, (Georgia has) determined that this is not a medical event. All documentation will be filed in the licensee's file and electronically. Notified the R1DO (Powell) and the NMSS Events Group via email. |
| ENS 54537 | 24 February 2020 14:20:00 | The following is a synopsis of a email from the state of Georgia: On April 3, 2018, the Georgia Radioactive Material Program was informed that a fixed nuclear gauge on the number 4 Digester had a shutter stuck in the open position (normal operation mode). The shutter was made operable on the same day, that the report was made to the state of Georgia. The gauge is a Kay Ray 7063-P and serial number 9132. The gauge contains 500 mCi of Cs-137. The gauge is in service with all radiation readings acceptable. There was no risk of exposure to employees or members of the public. |
| ENS 53241 | 2 March 2018 15:13:00 | The following information was obtained from the State of Georgia via email: On February 19, 2018, a patient was being treated with Y-90 SIR-Spheres. The targeted site was the liver. The prescribed dose was 39 mCi. The procedure appeared to go normally. A follow-up was performed on the same day. The physician thought the scan indicated there was no significant loss of material. On February 22, 2018, another intervention radiologist re-read the scan and noted approximately 30% entered the abdominal wall. On February 23, 2018, the patient was seen and complained of pain and reddening of the skin. The patient went through additional test to determine the cause. The RSO was notified on March 1, 2018 of the incident. The patient, physician, and manufacture were notified of the incident. The licensee will submit a more detailed report to determine the root cause, difference between the prescribed and delivered dose, dose to target organ and non-target organ. 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 53194 | 2 February 2018 13:50:00 | The following report was received via email: The radiographers placed the camera on a pipe, several feet from the ground, to take a shot. They did not secure the camera to the pipe. During the crank out process the camera fell off the pipe, face first, crimping the guide tube and causing the source to become stuck. The company called their radiographer crew located in Jacksonville, FL, to assist them in the retrieval of the source. The RSO and the helper from that office are trained in source retrieval. In the meantime, the area was cordoned off and secured until assistance could arrive. The incident occurred at approximately 1216 EST and completed the source retrieval at approximately 1900 EST. The source was not damaged. The exposure device and drive cable were put out of service and sent to the manufacturer for inspection/repair. The guide tube was damaged due to the fall and was disposed. The licensee will be submitting a report within a few days with detailed information. The licensee will be in the State for the remainder of the month providing us an opportunity to do an on-site inspection. Camera: QSA Model 880 Delta Source: Ir-192, 91 Ci RSO dose: 310 mrem, Helper dose: 118 mrem
After receiving the final report from the licensee, it was concluded that appropriate measures had been taken to limit overexposure from the source and corrective actions were set in place to reduce the likelihood of this incident reoccurring. The state of Georgia now considers this incident closed. Notified R1DO (Bickett) and NMSS Events (email). |
| ENS 52979 | 19 September 2017 10:38:00 | The following information was received from the State of Georgia via email: Emory University had new software installed for their HDR on 2/2/2016. During the time span of 3/2016 through 6/2017 (five) 5 patients received doses that were greater than 20% (percent) and greater than 50 rem to the targeted area. The misadministration was due to a software defect with Elekta's Oncentra Brachy Software version 4.5.2. using the ring applicator. The licensee was only aware of the defect on Aug 22, 2017 when Elekta notified all of their customers of the defect. Emory unofficially notified the State of Georgia on Aug 24, 2017 of a possibility that several of their patients may have been involved in a medical event. The medical event was confirmed on Sept 19, 2017 that (five) 5 patients were involved in a medical event. Cause and Corrective Actions: The events were due to a software issue utilizing the Oncentra Brachy Software version 4.5.2. A misadministration occurred due to an inconsistent step size when treating the ring source path. A source step size of 2.5 mm was planned. What was reported in the case explorer was a 5 mm step size. "Device/Associated Equipment: Oncentra Brachy Software version 4.5.2. in a Elekta Nucleotron MicroSelection v3 HDR using a ring applicator. The targeted area that received the greater than 50 rem was the tissue of the upper vaginal wall. The defect in the equipment is identified and described in EN #52922. 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 54644 | 7 April 2020 12:39:00 | The following is a summary of information provided by the State of Georgia via E-mail: Licensee personnel were performing three year wipe tests when one gauge was found to have a stuck shutter. The gauge contained a Cesium-137 source (Device: Model D14400S, S/N SE4029, Source; 250 milliCuries; S/N SNC250066). The gauge was not in service at the time of the wipe test. The licensee is planning on selling the gauge and having it removed from the premises. The company buying the gauge is aware of the stuck shutter and will fix the shutter before removing it from the licensee's premises. |
| ENS 52794 | 8 June 2017 15:22:00 | The following report was received via e-mail: Preston was sending a Troxler gauge to Troxler located in North Carolina for a repair of a faulty battery pack. Preston scheduled a package pick-up by (common carrier) on May 8, 2017 from Preston's Macon hub. The licensee stated the typical expected turn-around time for a gauge repair is 3 weeks. Troxler does not send the licensee a receipt confirmation when they receive the customer's gauge. On June 6, 2017, when the licensee had not received the gauge back from Troxler, they made a call to Troxler inquiring about the repair status of the gauge. Troxler informed the licensee they had not received the gauge. The licensee contacted (the common carrier) and asked them to track down the gauge. Based on the tracking information the licensee has, the gauge was last scanned on May 9, 2017 in TN. After some search, (the common carrier) scanned the package on either 5/18 or 5/19/17 at their International Bond Cage. According to (the common carrier), the package would have been scanned daily if it were shipped internationally. (The common carrier) will continue to search for the package. In the meantime, the licensee will follow-up with a written report. Sources: 8 mCi Cs-137 S/N 750-1945 and 40 mCi Am-241:Be S/N 47-24708 Device: Troxler 3430, S/N 28005 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 52341 | 2 November 2016 11:38:00 | The following report was received from the State of Georgia via email: Northside Hospital's Radiation Safety Officer called the Department (Georgia Radioactive Materials Program Environmental Protection Division) on 10/21/2016, informing us of a misadministration with the HDR (High Dose Rate) that occurred approximately two weeks ago. The patient was to receive 5 vaginal treatments consisting of 1 cylinder, 1 capri and 3 capris. The misadministration occurred during the second treatment. The capri was inserted into the rectum instead of the vagina. The Authorized User (AU) was not certain if a misadministration occurred until 2 weeks after the treatment. The AU requested the assistance of the radiologist who confirmed that the rectum was treated instead of the vaginal area. Based on the calculations, the rectum received approximately 350 cGy, what is to be considered a low dose. Additional information from the licensee will be forthcoming. Treatment material used: Varian Medical Systems, model: Gamma Medplus iX, with an Ir-192 source of less than 22 Ci. 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 51299 | 7 August 2015 15:58:00 | The following information was provided by the State of Georgia via email: The (Georgia) Radioactive Materials Program received a call on Aug 7, 2015 that a medical event occurred in the radiation oncology department at Wellstar Kennestone Hospital on August 5, 2015. The event was found out 2 days later when the physicist was reviewing the patient's records on Aug 7, 2015. Patient was being treated for cervical cancer (T&O implant) using the HDR (Ir-192, 5 Ci) . The authorized user had prescribed a treatment plan and then changed it to a reduced dose by 1/3 for 3 fractions. The first 2 fractions the patient received the reduced dose. On the third fraction, the 1st plan was delivered. The total dose delivered exceed the prescribed dose by (greater than) 20 percent and the fractionated dose delivered differs from the prescribed dose by more than 50 percent. The authorized user determined no harm came to the patient. The authorized user will be informing the patient on August 7, 2015. The dose delivered on the 3rd fraction was 900 cGy and for the T&O implant, the total dose received for all 3 fractions was 1500 cGy.
The following information was received via e-mail: First fraction delivered was 300 cGy Second faction delivered was 300 cGy Third fraction delivered was 900 cGy, should have been 300 cGy Total dosed received 1500 cGy On August 4, 2015, the patient received the first fraction. The physicist confirmed with the AU (Authorized User) that the plan was 900 cGy , 3 fractions and began the treatment. The dwell time for each fraction for the first plan was 1128.4 sec. After realizing how much dose was being delivered to the patient, the AU ordered to stop the treatment 219 sec into the treatment. A new written directive was prepared for 300 cGy per fraction, 900 cGy total. The first fraction continued to be delivered with the second plan. The total volume treated with the first plan was subtracted out from the seconded plan. The first two fractions the patient received the correct amount (300 cGy). On August 7, 2015, the patient was scheduled to receive her third fraction. When the patient's chart is pulled up on the computer console, both plans are displayed, the first plan and the second plan. The first plan auto defaults as the current plan being used. The physicist accidently used the initial plan (900 cGy/fraction) for the third fraction. It wasn't until August 7, 2015 when the physicist was reviewing the patients chart when she realized the first plan was delivered on the third fraction. The dwell time for each fraction should have been 350 sec. However, the dwell time for the third fraction was 1128 sec. The authorized user determined no harm came to the patient. The authorized user will be informing the patient on August 8, 2015. Notified the R1DO (Powell) and NMSS Events Resource (via e-mail). 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 49402 | 2 October 2013 14:02:00 | The following information was received from the State of Georgia via email: An authorized user exceeded the annual extremity limit for both the left and right finger. Landauer sent an immediate report (report date 9/23/2013) to the corporate office of Cardinal informing them of the over exposure. At the current moment, Cardinal does not know the time frame at which this took place, but should know in a week and a half when Landauer will send their monthly report. The immediate report issued by Landauer reported the following doses: Employee One, who resigned on August 13, 2013, received 57,554 mrem for the left finger and 52,681 mrem for their right finger. Employee Two received 22,016 mrem - left finger and 39,861 mrem - right finger. Employee Three received 43,140 mrem - left finger and 16,647 mrem - right finger. Cardinal will be investigating the incident to determine the root cause. They will be looking a systemic issues at the facility. Georgia Incident Number: 72258 |
| ENS 48578 | 11 December 2012 09:31:00 | Georgia Tech was wipe testing the Ni-63 source from a gas chromatograph. The source was determined to be leaking and had contaminated an adjacent counter top. The source was last "refoiled" in May 2011. |
| ENS 45846 | 16 April 2010 17:02:00 | On April 13, 2010, a student at the Georgia Institute of Technology (the licensee), under the supervision of an authorized user, was conducting an electroplating experiment, using Ni-63, under a fume hood in one of the licensee's RAM (Radioactive Material) rooms. During the experiment, the student noticed fumes outside the hood and ceased the experiment. She took a swipe outside the hood and found no contamination. On April 14, the licensee's Radiation Safety Officer took swipes of the room and found 22,000 DPM of contamination on the fume hood lip, 11,000 DPM on the RAM room floor, 1,200 DPM on a public hallway floor outside the RAM room, and contamination in an adjacent RAM room. All areas have been cordoned off to control access and cleanup is in progress. It is unknown whether the student had any uptake, was overexposed, or was contaminated during the event. |
| ENS 45246 | 5 August 2009 14:08:00 | During an embolization procedure delivering Yttrium-90 spheres to the liver an interruption occurred resulting in only 35 Gy of the 52 Gy prescribed dose being delivered. The interruption was due to unexpected contamination due to a leaking septum v-vial Contamination was contained in a container and did not enter the patient. The patient and referring physician will be notified. GA report number: 2009-09i. 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 44599 | 24 October 2008 14:46:00 | The licensee notified the State of Georgia on 10/23/2008 regarding a dose of greater than 500 mrem administered to the fetus of a pregnant patient. The apparent unintended dose was identified by the licensee on 10/22/08. The State of Georgia is attempting to contact the licensee for additional follow-up details and a report related to this event.
The following information was provided to the State of Georgia by the licensee: The patient was administered the radiopharmaceutical on October 13, 2008. Our facility was informed of the patients pregnancy on October 22, 2008. The RSO and our consulting medical physicists were notified. A dose calculation was performed and it was determined that the embryo/fetus received an effective dose equivalent in excess of 500 millirem. The patient was scheduled for a Nuclear Cardiology treadmill stress test on October 13, 2008. The patient was asked by the staff if she was pregnant per facility policy. The patient indicated that she was not pregnant. This was documented by our staff. The patient was administered 10 mCi Tc-99m Myoview for resting procedure and 30 mCi Tc-99m Myoview for stress. The patient subsequently determined she was pregnant and notified us as described above. The patient withheld information regarding pregnancy and fertility medication when asked prior to the study. The dose to the conceptus is estimated to be approximately 1.12 rad with an uncertainty factor of 50 percent. Determination of dose is limited by patient habitus and metabolic parameters. The prescribing physician was notified October 23, 2008 at 9:34 AM and stated that she will notify the primary physician and patient. Notified R1DO(Cobey) and FSME(Mauer) |