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| Entered date | Event description | |
|---|---|---|
| ENS 56600 | 30 June 2023 11:33:00 | The following information was provided by the Oklahoma Department of Environmental Quality (DEQ) via email: On June 26, 2023, a referring physician ordered 300 microcuries for an I-123 thyroid and uptake scan. Instead, outpatient scheduling ordered a 21.1 millicuries Tc-99m sestamibi parathyroid exam. Neither the registration nor the nuclear medicine department reviewed the physician's order, and the Tc-99m sestamibi was administered. Using the nuclear medicine dose tool, the radiation dose estimates provided by the licensee for the I-123 uptake and scan would have been an approximate effective dose equivalent of 0.24 rem with the thyroid being the critical organ receiving 5.20 rad. Using the nuclear medicine dose tool, the radiation dose estimates provided by the licensee for the Tc-99m sestamibi parathyroid exam was an approximate effective dose equivalent of 0.62 rem with the gallbladder being the critical organ receiving 3.83 rad. In his email, the radiation safety officer stated that their local steps after this incident will be: to have in-depth conversations with techs and outpatient scheduling manager; initiate an incident report (internal and misadministration form); make notifications to the patient and attending physician; and engage the risk management and internal sentinel event process. The incident will be documented and reviewed in the July radiation safety meeting. It will also be reviewed during the daily facility safety meeting with C-Suites and all facility directors/managers. Additional updates will be made as they are received according to SA-300. DEQ Event #1278
The following is a summary of information provided by DEQ via email: The event was not a reportable medical event due to not meeting the threshold for reporting under 10 CR 35.3045(a)(1)(ii)(A). Notified R4DO (Drake) 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 55604 | 24 November 2021 09:05:00 | The following was received via email from the Mississippi State Department of Health (the agency) via email: On 22 November 2021, the licensee notified the Agency by email regarding an incident that took place on 19 November 2021. The (Berthold Technologies) reciprocity crew, working under reciprocal recognition, was conducting turn around, replacing three gauge systems at the Licensee plant's Operating Processes. Two of the three sources retracted while one source was discovered to be stuck in the dip tube (Source Information: Co-60, 7.43 mCi, Manufacturer/Model: EG&G Berthold Model P-2608-100, Serial #: 1540-08-05, Device Information: Manufacturer EG&G Berthold, Device Model#: LB 7671, Serial Number: TBD). Reciprocity personnel attempted to dislodge the source to get it to retract but all attempts failed. The technician attached a blind plate (surveys below background) to prevent access and he documented surveys which the reciprocity personnel stated will be provided at a later time. According to the reciprocity licensee personnel, surveys were approximately 0.2 to 0.3 mR/hr at the detector side. Licensee personnel stated that the source is secured and remains shielded. Reciprocity licensee stated that they will continue to consider options to dislodge the source. The investigation into this event is ongoing and information will be provided as it is received in accordance with SA-300. Mississippi Item Number: MS-210003
The following information was received from the Mississippi State Department of Health (the agency) via e-mail: Investigation findings indicate this event is not reportable. The highest survey reading is 0.2 mR per hour. This does not exceed public dose limit or an exposure that would cause a 25 milllirem TEDE. It is not lost or stolen. The source activity is 0.64 mCi. The source is at the top of the dip tube in the normal operating position in a safe position. The tank is approximately 30 foot tall and 20 foot wide in which the tank and the fluid is shielding the low activity source. The source will not expose the workers. The tank and gauge are on the 3rd floor of the refinery and only RSO's and workers supervised by RSO are allowed in this area. The engineer tried to remove it from this position for a scheduled source change out, and it could not be removed. At present, without shutting the production line down which makes plastic, this could cause a revenue loss of millions of dollars to the company. In the opinion of the Mississippi Health Physicist, this is not reportable. It does not meet SA 300 reporting requirements. The RSO has agreed to perform surveys at shift change and report any changes. This event is closed. If any changes occur and are reported. The agency will meet reporting requirements. Notified R4DO (Groom) and NMSS Events (by email). |
| ENS 55502 | 1 October 2021 23:46:00 | The following was received from the Mississippi Division of Radiological Health via email: On 30 September 2021, a Radiography crew was conducting radiography testing of a 12 inch pipe located at Plant Dudley, 308 Moselle Seminary Road, Moselle, Mississippi. During their test, the crew realized the 118 Ci, Ir-192 source (QSA Global, Sentinel, Serial#: 33736M) was not in the camera (QSA Global, Sentinel 880D, Serial#: D6695). The crew notified the Radiation Safety Officer (RSO) at approximately 1300 EDT and he instructed them to cover the collimator with lead shot bags and additional shielding. Upon arrival into the restricted area and (after) four (retrieval) attempts, the RSO discovered the cable behind the connector had separated (130 mR total on (RSO) pocket dosimeter). The collimator was facing down and the source was 90 percent shielded, according to the RSO. The RSO was approximately six inches from the source as he cut away the tube, which lasted for three and half to four minutes (saturated pocket dosimeter and electronic dosimeter read 6 R). During the entirety of the incident, the location was secure and under constant surveillance. Weather in the area was rainy. Upon completion of the source retrieval, the RSO brought the crank/cable to the Applied Technical Services (ATS) Metallurgy Lab to perform a chemistry and forensics investigation. Once the ATS, Inc. investigation is complete, the crank/cable will be sent to QSA Global. Currently, the camera is being stored at the Alabama storage location. Mississippi Event Number: MS-210002
The RSO sent his dosimetry results to Landauer for immediate processing, and he received the results, Tuesday, October 5, 2021. Please see below: 7/1/2021-9/30/2021: Collar: DDE: 1456 mrem LDE: 1460 mrem SDE: 1461 mrem Rt Finger: 10255 mrem Lt Finger: 35538 mrem Rt Ankle: 721 mrem Lt Ankle: 336 mrem 9/1/2021-9/30/2021 Chest: DDE: 2581 mrem LDE: 2581 mrem SDE: 2530 mrem Quarter 3 Collar and Chest: DDE: 4040 mrem LDE: 4045 mrem SDE: 3995 mrem Rt Finger: 10255 mrem Lt Finger: 35538 mrem Rt Ankle: 721 mrem Lt Ankle: 336 mrem Total Year to Date: Collar and Chest: DDE: 4045 mrem LDE: 4052 mrem SDE: 4015 mrem Rt Finger: 10255 mrem Lt Finger: 35538 mrem Rt Ankle: 721 mrem Lt Ankle: 336 mrem The investigation into this event is ongoing. Information will continue to be provided as it is received according to SA-300. Notified R1DO (Carfang), R4DO (Dixon) and NMSS Events Resource (email). |
| ENS 47451 | 17 November 2011 16:31:00 | The following report was received from the Mississippi Division of Radiological Health (DHR) via e-mail: The licensee's RSO contacted DRH to report the theft of their Troxler Model 3440 (S/N 22563) nuclear gauge that was secured in the back of their white marked pick-up truck parked six spaces from the front entrance of the Wal-Mart (located in Meridian, MS). The two gauge cables were cut and the gauge was taken out of the truck bed. All required shipping documentation was stolen out of the unlocked cab of the truck. The gauge and gauge paperwork were estimated to have been stolen around 1820 (CST). The gauge was stored in the yellow plastic transport case with Radioactive Yellow II labels attached. The yellow plastic transport case had two locks on the outer container and two cables threaded through the top handle and locked with two separate locks on each separate eye hook. Meridian City Police were immediately notified by the licensee. Licensee notified Mississippi Emergency Management Agency (MEMA) at 1940 (CST). MEMA contacted DRH at 1955 (CST). DRH notified Department of Homeland Security (DHS) who then notified FBI. DRH performed an inspection and investigation on November 16, 2011 at Terracon Consultants, Inc., in Ridgeland." The gauge contained the following sources: Cs-137 (S/N 75-4297) (8 mCi); Am-241:Be (S/N 47-18403) (40 mCi) Mississippi Report MS-11006 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 |