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| Entered date | Event description | |
|---|---|---|
| ENS 56805 | 20 October 2023 12:44:00 | The following information was provided by the Florida Bureau of Radiation Control (the Bureau) via email: This is a medical event resulting from an overexposure of the breast. A 52-year old female was being treated with 10 fractions of High Dose Rate I-192. The total dose was to be 34 Gy total. The estimated actual dose was 30 percent greater. The delivery system is on a windows XP based personal computer and due to computer security, a windows XP based computer cannot be on the network. Because of this (configuration), the planning and delivery systems are not linked. (As a result,) staff did not verify the dwell times between the planning and delivery systems, resulting in using an incorrect dwell time. Eight (8) fractions were delivered with incorrect dwell time before this was noted. 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 56776 | 4 October 2023 14:37:00 | The following information was provided by the Florida Bureau of Radiation Control (the Bureau) via email: On October 4, 2023, a gamma density gauge (DensityPro Gamma Density System, Model Number 5201A, 20 mCi Cs-137) was discovered in a rejected load of scrap metal at NuCor Steel. The Bureau inspector took custody of the gauge and transported it to Orlando. Upon further cleaning, the description plate revealed a serial and model number. The gauge was determined to belong to James Hardie Building Products (licensee). The licensee will be contacted and further corrective actions will be referred to the materials group at the Bureau. Florida Incident number - FL23-152 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 54786 | 17 July 2020 09:49:00 | The following was received from the Florida Bureau of Radiation Control (BRC) via email: On July 16, 2020, a 54 year old man was mistakenly provided two doses of Tc-99 Sestamibi for heart stress test. Two doses were administered with a total activity of 41.6 mCi, estimated dose of 7.49 R, to the intestinal wall. The RSO ((Radiation Safety Officer)) reports that standard verification process for patient identification prior to dosage was not followed. Patient and patient's cardiologist have both been notified, no effects of the mis-dose are expected. The RSO will provide additional info in the 15 day letter to BRC. Licensing and Technology will be tasked to investigate. Florida Incident Number FL20-081 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. |