Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 57011 | 6 March 2024 09:14:00 | The following information was received from the Georgia Radioactive Materials Program via email: The licensee reported on 3/5/24 about an incident at Piedmont Hospital with Y-90. They underdosed a patient when the catheter was put in the artery. There were vein convulsions which caused only about 30 percent of it to be administered. The licensee stated it did not cause stasis. A follow up with a report will be submitted to the Georgia Environmental Protection Division within 15 days. Georgia Incident Number: 79 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 56799 | 16 October 2023 13:14:00 | The following is a summary of information provided by the Georgia Radioactive Materials Program via email: On September 14, 2023, the licensee determined that an iodine-125 seed used for non-palpable lesion localization had been lost. Two seeds had been previously implanted in a patient. On September 12, 2023, a specimen containing both seeds was removed from the patient. When transported to pathology lab, only one seed was located in the specimen. It was confirmed through survey and imaging that the seed was no longer in the patient, and it is suspected that the seed was lost in the operating room. At the time of the loss, the seed had an activity between 0.218 and 0.221 millicuries. After conducting a search of the operating room, the surgical equipment, and the pathology lab, the radiation safety officer declared the source lost on September 14, 2023. Georgia NMED Incident Number: 71 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 56426 | 22 March 2023 14:44:00 | The following information was received from the Georgia Radioactive Materials Program via email: Radionuclide: Cs-137 Vial; Serial Number: 1360-12-8; Current Activity: 0.035 mCi During a routine sealed source inventory check on March 17, 2023, a physicist identified a damaged spot on the referenced Cs-137 vial. The source was wiped and then immediately placed back into its shielded container. The outer area of the container was sealed with tape, and all potentially contaminated items (e.g., gloves, tape, wipes, etc.) were triple bagged, sealed, labeled, and placed in a storage cabinet in the hot lab. Area surveys and wipe tests performed in the location where the source was located showed no signs of contamination. As such, the leaking source has been fully contained and is currently secure in the hot lab. The leak test samples were acquired and analyzed on March 17, 2023. We (the licensee) are currently in the process of obtaining quotes from various hazardous waste disposal companies in our region. Once the source has been properly disposed of, we (the licensee) will notify your department (Georgia Radioactive Materials Program) and provide relevant documentation. Georgia Incident Report No.: 63 |
| ENS 56007 | 21 July 2022 15:01:00 | The following information was provided by the licensee via email: This is a preliminary report. A male patient was prescribed 100 millicuries of lutetium-177. He was delivered with 204 millicuries instead on July 20. This was the patient's third round of lutetium-177. The first two rounds were delivered at 100 millicuries as prescribed. Patient has been notified of the misadministration per a phone call from the prescribing physician. Emory University will send a more thorough report of the misadministration. More information is to follow. Georgia Incident No: 55 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 55642 | 13 December 2021 09:55:00 | The following is a summary of information received from the state of George via email: A portable troxler gauge (Model 3430) with an Am-241/CS-137 was lost by a common carrier. The activity of the source is unknown at this time. Serial Number: 21711 Am-241 Source Serial Number: 47-16983 Cs-137 Source Serial Number: 75-3259 Georgia Incident Number: 19
CS -137 Manufacture Radiological Specification (8mCi plus or minus 10 percent) Am-241 Manufacture Radiological Specification (40mCi plus or minus 10 percent) 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 55386 | 30 July 2021 13:47:00 | The following information was received from NMED for the Georgia Radioactive Materials Program: This incident occurred on July 14 at Piedmont Fayette Hospital (GA 1340-1). The unnecessary study was an administration of 25.6 mCi of Tc-99m exametazime-labeled white blood cells (Ceretec WBC), for which the TEDE was about 9 mSv. The individual who received the unnecessary study only came to the hospital for the study and was not an inpatient or there for any other reason. Georgia Incident Number: 45
The following is a synopsis of the root cause conducted by the Piedmont Fayette Hospital: The order for the study was received by the imaging center on June 2, 2021. However, the order date for the study was December 16, 2015. The reason for this discrepancy was due to a training mishap at the ordering doctor's office. Staff at the imaging center did not observe the date discrepancy between the fax date at the top of the page and the order date in smaller print elsewhere in the document. The individual receiving the dose had not seen the ordering physician since 2015. At the time the order was received, the individual receiving the dose was under the care of a different physician than the ordering physician and the individual receiving the dose assumed that the different physician had ordered the study. The hospital Radiation Safety Officer (RSO) has concluded that, because the individual was not actually a patient, the exposure should be reclassified as an exposure to a member of the public, which has lower reporting limits than a misadministration. The TEDE was approximately 8.5 mSv (0.85 rem). No ill effects are anticipated from this exposure. The hospital has initiated re-training for staff to preclude similar confusion going forward. Notified R1DO (SCHROEDER) and NMSS Events Notification group. 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 54565 | 5 March 2020 11:41:00 | The following information was received from the State of Georgia via email: On June 29, 2018, it was brought to the (Piedmont Fayette Hospital Radiation Safety Officer's) RSO's attention that a radioactive seed containing 62 microCuries of Iodine-125 was unaccounted for and could not be located. The seed was manufactured by Best Medical International, Inc., Model 2301. The physical form is a double wall titanium tube containing a tungsten x-ray marker that is coated with I-125. The source serial/lot number is 45876A-26. The source was calibrated at 100 microCuries on 5/11/2018. On the morning of the seed implantation procedure, 6/27/2018, the source measured at 62 microCuries in the dose calibrator in the hot lab. The seed had been used for localization of a breast lesion. Tissue was extracted from the patient and the specimen was reported to have contained the seed at the time of specimen radiography. Following this radiography procedure, the seed appears to have been lost. All efforts were made by staff on-site to locate and search for the seed in all possible locations, with no success. The patient was brought back in for radiology procedures to ensure that the seed was not still contained in the patient. Results of x-rays showed that the seed was not present in the patient. According to the RSO, it is likely that the seed was disposed of along with the trash collected after the procedure, or possibly washed down the floor drain in the specimen radiography room. According to the RSO, this is a best guess as to the fate of the seed. No individual members of the public or staff were likely to have been exposed to significant doses of radiation, based on the available information submitted to EPD (Georgia Environmental Protection Division). 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 54563 | 5 March 2020 11:08:00 | The following information was received from the State of Georgia via email: (The Radiation Safety Officer) of Phoenix Technology reported a leaking cesium-137 source from one of their clients (Myers Cardiology). During a source change out on November 6, 2017, it was noted that the old source was leaking. The activity of the leaking source is 203 microCuries, and the leak test results are 26 nanoCuries. The leaking source was placed inside a protective pig and inside a plastic bag labeled as a damaged source. The source has been sent to Pinestar Technologies in Pennsylvania for proper disposal. Source Manufacturer: IPL Source Model No.: MED-3550 Source Serial No.: 986-15-17 Georgia Item Number: GA170001 |
| ENS 54564 | 5 March 2020 11:08:00 | The following was received from the State of Georgia via e-mail: The Georgia Radiation Materials Program received a call from the (Radiation Safety Officer) RSO from Grady Memorial Hospital on August 12, 2016, stating the (200 microCurie) I-125 seed used for localization of non-palpable lesions was lost. The doctor performing the procedure stated the seed went into the tube of the suction tank. A survey of the suction tank, hallways and operating room did not uncover the lost source. The tissue, removed from the patient, which was transferred to pathology, also did not contain the source. The surveys of the hallway and operating room were performed after the hospital was notified. The RSO recommends bringing the patient back in the hospital to be surveyed to verify if the source was ever removed from the patient. At the time of the call, the RSO has been unable to speak to the doctor. The doctor is a surgeon and not an authorized user. The RSO stated the tube to the suction tank cannot be found and it may have made its way into the biohazard container. The RSO will follow-up with the biohazard department to see if the tube can be traced down so the tube can be surveyed to determine if the source became lodged within it. The RSO is also trying to follow-up with the doctor for more information. NMED Report ID: 160362 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 |