Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 49274 | 13 August 2013 14:22:00 | The following information was obtained from the State of Oregon via email: A Troxler portable moisture density gauge was stolen out of the back of a worker's truck around 2:30 AM (PDT) on August 2nd, 2013. The gauge was recovered by the Sherwood police within the hour and returned to worker. The gauge handle and case remained locked. The only locks breached were the locks securing the device in the back of the truck. The licensee was just informed of the theft and reported it to Oregon RPS (Radiation Protection Services) at 10:00 AM on August 13th, 2013. The licensee will conduct further investigation and develop corrective actions. This information will be reported to Oregon RPS within 30 days. Device: Troxler 3430 SN: 38580 Sources: 9 mCi Cs-137 and 44 mCi Am-241/Be Oregon Incident #: 13-0029 |
| ENS 48753 | 14 February 2013 18:29:00 | The following is a synopsis of information received from the State of Oregon via email: When cleaning out an attic storage space acquired from a business partner (Philco International), an employee of the Evonik Corporation discovered a gas chromatograph containing a Ni-63 electron capture device (ECD). The ECD was manufactured in 1993 and contained 15 mCi of Ni-63 at the time of manufacture. The ECD is model number N610-0133 and serial number 1121. The chromatograph was manufactured by Perkin Elmer and was originally sold to InterMedics of Angleton, TX in October, 1993. In 1998, Guidant bought out InterMedics and eventually closed the facility in 1999. It is unknown what happened to the device after the 1999 closure. Evonik Corporation will be contracting out proper disposal of the unit and will inform the State of Oregon when it has been removed. Oregon Incident No.: 13-0009 |
| ENS 48207 | 20 August 2012 13:26:00 | The following information was received from the State of Oregon via email: (The licensee reported) a misadministration on Monday, August 13, 2012, during a treatment with (Y-90) TheraSpheres. The misadministration was due to a malfunction of the syringe plunger of the delivery device, and is the first time that this problem has occurred at Oregon Health & Science University. This was a two-vial treatment, and the malfunction occurred with the first delivery set. (The activity from the second vial, and with a new delivery set, was administered with no difficulty. Delivery sets are single-use.). The nurse who was setting up the system, and who routinely sets up the systems, noticed a stiffness when she was snapping the plunger into position through the vial septum. She was not able to retract the needles (the plunger is designed not to be removable), and it appeared to be placed properly. The physician was informed of the 'stickiness'. The patient's catheter was correctly hooked up to the delivery device, and the catheter in the patient was in the desired position. As soon as the administration was started, blood backed up into the catheter, which was unusual. Normal attempts to administer the activity by pushing saline into the vial resulted in fluid running into the over-pressure vial. The treating physician ended the attempt to deliver the activity, and the system was removed in the normal way by placing the used items in the waste container. The second delivery set and the second dose vial were placed in position, the patient catheter hooked up, and the delivery of the activity went smoothly. The patient was notified of the problem and of the possibility of a retreat. The Oregon Department of Health Radiation Protection are waiting for the Nordion technical adviser to call mid-day today. The Y-90 TheraSphere treatment consisted of: Vial 1 - Script 66 Gray, Administered 12 Gray, 81.8 % Error of 54 Gray Vial 2 - Script 55 Gray, Administered 50.2 Gray, 8.7 % Error of 4.8 Gray Treatment Total - Script 121 Gray, Administered 62.2 Gray, 48.5 % Error of 58.8 Gray Oregon Incident # - 12-0031 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 48050 | 27 June 2012 11:30:00 | (Metro Metals) phoned that a flatbed truck with metal scrap from a recycler in WA (Paymore Recycling & Salvage, Montesano, WA) set off their portal monitor. Hand-held exposure meters were used to survey the load and levels were found at 4000 microrem/hr. This load is waiting for RPS (Radiation Protection Services) to check. Responded to Metro Metals. Found a static bar. Wrapped and sent back to recycler. Max reading, with Ludlum 2401 EC, at front edge of bar was 6 mR/hr. Exploranium identified Am-241. Static bar was about 5 to 6 feet in length and was cut in half. Item was wrapped in plastic and placed in a drum for return to the recycler. Radiation Protection Services No: 12-0020 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 49282 | 15 August 2013 14:05:00 | The following information was received by email: Based on protocol, a dose of 120 Gy (1.79 GBq) was prescribed. Upon completion of the treatment, survey of the Nalgene waste container measured higher than expected. Ensuing calculations resulted in dose delivered to be 85 Gy (1.24 GBq); greater than 20% variation from prescribed dose. All drapes, towels, etc were surveyed with no evidence of radioactivity present, therefore assuring no contamination present. Contents of the waste container were measured separately to locate the source of residual activity. The readings indicated minimal activity in the Y -90 vial; readings of the patient delivery microcatheter were indicative of residual microspheres. The treatment protocol was followed with no variations of procedure. As is typical, 3 saline flushes were made of the catheter including several vigorous flushes to dislodge any microspheres as recommended by Nordion, the product manufacturer. No high pressure was detected at any point during infusion which would trigger the pressure valve and deliver saline in the overflow vial. There was no build up of particles in the hub of the delivery catheters as inspected throughout the procedure. Measurements over the length of the catheter revealed greatest activity in the proximal portion of the catheter with little-to-no activity in the tip. Nordion has been contacted. In the future, survey of the catheter prior to disconnecting it for disposal may help detect the build-up of particles. Oregon Incident: 11-0037 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 47155 | 15 August 2011 19:10:00 | The following was received via email: On Friday August 12, 2011, the gauge owned by the licensee had been run over by a roller. The licensee reported that the gauge was in the shielded position and there were no elevated readings on the gauge. The gauge was placed into the shipping case and returned to the office for disposal. The device was a CPN MC moisture density gauge serial number M390104801 containing 10 milliCuries Cs-137, Am-241/Be 50 milliCuries. Incident #: 11-0028 * * * UPDATE FROM DARYL LEON TO PETE SNYDER AT 1253 ON 10/19/11 * * * On August 17, 2011, the above source was received by Qal-Tek of Idaho Falls, ID who possesses NRC license 11-27610-01, for disposal. Both sources passed a leak test performed by Qal-Tek. Notified R4DO (Campbell). |
| ENS 45681 | 4 February 2010 18:30:00 | Licensee, Georgia Pacific Toledo, notified the Agency (Oregon Department of Health and Radiation Protection) that the 6 month inspection on their K-Ray fixed gauge (model 7062B) revealed the shutter would not close correctly. The gauge was still able to perform it's function as a level indicator on a coal bin. Licensee called the manufacturer for repairs. Source is 50 mCi of Cs-137. Incident Report # 10-0005
On February 10, 2010 the licensee's RSO (Radiation Safety Officer) and the vendor technician verified the fixed gauge shutter functioned correctly. It was observed that the time constant on the detector was quite long. The RSO and the vendor determined that the initial report of a shutter malfunction was in error because personnel did not wait long enough to see the result of closing the shutter on the control system. The licensee will add a note to the inventory form for this source as to the name of the control tag for the detector in order to verify the closed/open shutter transition and to see an adequate response. No other action is required on this incident and the State of Oregon recommends that that the incident be closed. Notified the R4DO (Cain) and FSME (McIntosh). |
| ENS 44786 | 20 January 2009 13:11:00 | The State of Oregon provided the following information on damaged tritium exit signs (TES) contained in 7 separate reports from Wal-Mart. 1. Serial # 256279, Activity: 11.5 Curies, Date of Damage: unknown: Store Location: 3025 Lancaster Drive, NE Salem, Oregon 2. Serial # 275536, Activity 20 Curies, Damage Date: unknown: Store Location: 3002 Stacy Allison Way, Woodburn, OR 3. Serial # 283177, Activity 20 Curies, Damage Date: unknown: Store Location: 3002 Stacy Allison Way, Woodburn, OR 4. Serial # 271065, Activity 20 Curies, Damage Date: unknown: Store Location: 2051 Newmark Ave., Coos Bay, OR 5. Serial # 286545, Activity 11.5 Curies, Damage Date: unknown: Store Location: 3600 Washburn Way, Klamath Falls, OR 6. Serial # 292245, Activity 20 Curies, Damage Date: unknown: Store Location: 135 N.E. Terry Lane, Grants Pass, OR 7. Serial # 292236, Activity 20 Curies, Damage Date: unknown: Store Location: 135 N.E. Terry Lane, Grants Pass, OR Wal-Mart retained Shaw, an environmental services contractor with extensive experience with management of radioactive material, for its company wide program to inventory TES." Shaw has remediated the areas, if necessary, and has either returned the signs to the manufacturer for repair or proper disposal. Wal-Mart has implemented and communicated protocols to its stores for the proper handling of TES to ensure public health and safety and protection of its employees. |
| ENS 43445 | 26 June 2007 19:12:00 | On June 25, 2007, during a patient treatment, the computer operating the Varian VariSource High Dose Rate After loader reported an error 18, Wire drift detected. This indicated that the source wire positioning system was out-of-specification and the HDR was terminating treatment. Treatment was immediately discontinued and the patient removed from the room. The positioning QA was performed and the system found to be within typical operating limits. The treatment was resumed, but the same error recurred. Treatment was discontinued with only a partial treatment delivered. No errors in positioning or site occurred. The physician and patient were notified immediately after the treatment was terminated. Varian Service was notified of the occurrence and a field engineer was dispatched to clean the system the following day. The source and dummy wire transport systems were cleaned and tested. The medical physicists performed several QA tests concerning positioning and source output, and certified the HDR After loader system as ready for patient treatment. Dosimetry reconstruction of the delivered dose indicates that 17.8% of the prescribed dose was delivered. Physician will reconstruct new treatment plan. Treatment Details: The patient was receiving HDR treatment #2 to a Miami vaginal cylinder with tandem. This apparatus is connected to the HDR After loader (with radioactive wire) with 7 separate connecting tubes, one for each treatment channel. During connection, bloody fluid was noted on one of the connectors, cleaned, and the tube connected. The treatment was initiated, but after that tube was treated, the device's computer indicated the wire positioning was not reproducible (error code 18 - Wire drift detected) and the treatment was paused. The QA positioning test was run and within acceptable limits. The treatment was continued, but the device again indicated positioning errors. The treatment was discontinued without being fully completed. Protective caps covering the tubes were removed in surgery instead of waiting until the patient arrived in the department, a typical procedure that had not caused an incident in the past. In the future, it is prudent to leave them connected until the patient is ready to be connected to the treatment device. Two lessons learned from this experience: For HDR cases using a tandem, the tandem channel should be treated first, since the prescribed dose is more influenced by tandem dose than by ovoids or vaginal cylinder. The protective caps on the applicator should be left on as long as possible to reduce or preclude any fluid in the closed system. Device: Varian VariSource High Dose Rate After loader, S/N#: 600379, SS&D #: CA-0661-D-103-S, Source: Alpha - Omega Model #: VS 2000, SS&D #: CA-1080-S-102-S, S/N #: 02-01-0588-001-041907-10089-97, Activity: 10.089 Ci on 4/19/07
This event (EN43443) has been reviewed and determined to be a reportable medical event. 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 43214 | 5 March 2007 15:38:00 | The State was notified by the licensee's RSO that a patient had an underexposure by 24%. The State will provide updates as licensee information is received. 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.
After review of the event by the licensee and the State, the material involved in this event (Palladium -103) is accelerator produced and is not regulated by the NRC. Therefore, this event is not reportable and is retracted. Notified R4DO (Shannon) and FSME (G. Morell) |
| ENS 42833 | 7 September 2006 17:45:00 | Cascade Steel located in McMinnville, OR received a rail shipment of scrap steel which triggered a portal alarm. During the investigation, a Texas Nuclear Gauge Model 5193, S/N B1207, containing 500 mCuries Cs-137, dated October 1978, was recovered. Thermomeasure Electronics, formerly Texas Nuclear, was contacted and confirmed that the last owner on record was Astaris of Pocatello, ID which may be out-of-business. Thermomeasure Electronics collected and disposed of sources at this location in 2002. Thermomeasure Electronic records identify the source S/N is MA5033 and that a total of eight (8) devices and one (1) gauge associated with Astaris are unaccounted for. The State of Oregon is enroute to the Cascade Steel facility to recover the source. |
| ENS 42799 | 23 August 2006 19:35:00 | The State provided the following information via facsimile: Event Description: "A researcher reported that a vial containing I-125 labeled hormones is missing. They had received a shipment from another university that was supposed to have had 3 vials. The person who checked in the package did not realize there were supposed to be three vials. The material was packaged with dry-ice. Only two vials were removed from the package and the package was placed in the trash. When it was discovered that they were supposed to be three vials, the trash had already been removed and the dumpster taken away. The estimated amount is 237 microCuries of I-125. Corrective Actions: "Licensee will double check inventory of each box during unloading. |
| ENS 42798 | 23 August 2006 19:35:00 | The State provided the following information via facsimile: Doctor treated wrong Trigeminal nerve. Patient received 32 Gray before error was noted. Doctor informed patient of error then proceeded to treat correct nerve. In order to prevent a reoccurrence of this mistake, there will be three different double checks undertaken on the day of treatment. Prior to being sedated, the patient will be asked which side his or her pain is on. When the patient, is framed the nurse shall ask the neurosurgeon which side is to be treated. This will be verified with the patient. Lastly, just prior to treatment, both the neurosurgeon and the radiation oncologist will be once again asked which side is to be treated on the patient. This triple check system should prevent this mistake from happening again. |