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| Entered date | Event description | |
|---|---|---|
| ENS 55331 | 30 June 2021 10:42:00 | The following event report was received via e-mail from the Florida Bureau of Radiation Control (BRC): The vice president (VP) of the licensee called the BRC at 1015 EDT to report that a SMDG ((small moisture density gauge)) was hit or run over by a front end loader at 1010 EDT this morning. The location is a construction site north of the intersection of Connorton Blvd. and US-41 Land O' Lakes, FL 34637. The VP intends to evaluate SMDG, then send it to Troxler. The VP will provide a written report to the BRC. Florida Incident Number: FL21-087 |
| ENS 55293 | 5 June 2021 11:19:00 | The following was received from the Florida Department of Health (FDH) via email: Source: Co-60, Gamma-Knife treatment Dose to brain lesion: 15 gray in Orlando, 18 gray in Colorado On April 27, a patient was consulted for a Co-60, Gamma-Knife treatment at Advent Health Orlando. The original (Adventist Health Orlando) Radiation Oncologist was made aware of previous treatment in Colorado and requested medical records. However, for two weeks in mid-May, the original Radiation Oncologist went on vacation. Then on May 14, the patient received Gamma Knife treatment from a different (Adventist Health Orlando) Radiation Oncologist. 13 brain lesions were treated. On May 17, the patient's records from Colorado were received by Advent Health Orlando, where on June 4 the original Radiation oncologist reviewed patient's records and discovered that, to 1 of the 13 lesions, the patient received 18 gray of treatment from a linear accelerator in Colorado, then received 15 gray of treatment from a Gamma Knife in Orlando. The Radiation Safety Officer (RSO) called (FDH) at 1000 EST on June 5, to report a potential medical event involving a duplicate treatment of a gamma knife to a patient. The patient and the physician have been notified. The RSO stated that in the future, but not the present, unintended clinical consequences to the patient's target organ are expected as a result of this incident. Florida Event Number: FL21-074 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 55258 | 13 May 2021 21:25:00 | The following was received from the Florida Department of Health (Bureau of Radiation Control) via email: At around 2020 (EDT) this evening, (the licensee) reported a lost radiography source from the Nuc-Med department. It was confirmed as missing from the lead pig this morning by a PET-CT tech after performing a (quality control) QC check on the camera. The PET-CT tech believes that they put it in their pocket yesterday afternoon after they were finished using it, instead of putting it back in the pig. (The) licensee reports to have used four detectors in the work area, and in the PET-CT's car and residence, but the source is still missing. Source: Na-22 Activity: 100 uCi on 01 June 2018, 45uCi today Manufacturer: Eckert & Ziegler Serial Number: Q5-225 Florida Event Number: FL21-063 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 55136 | 12 March 2021 16:49:00 | The following is a summary of an email from the state of Florida: At 1600 (EST), the (Radiation Safety Officer) RSO called to report a radiation underdose. Following the procedure, the waste was collected and measured to calculate the actual activity delivered. The actual activity delivered was 0.76 GBq, 90 percent of the prescribed treatment dose. Post procedure, during the room survey, inside the Plexiglas Administration Box a high level of activity was detected. The box was placed in double bags and relocated to the waste storage area. An investigation into the event is ongoing to calculate the activity in the box following administration. No individuals were contaminated and there was no harm to the patient. Florida Incident Number: FL21-038 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 55102 | 12 February 2021 09:29:00 | The following report was received via email from the Florida Bureau of Radiation Control (BRC): On February 12, 2021, on or around 0830 (EST), a Wingerter Laboratories (employee), License 0673-1 Cat 3L(1), called the BRC to inform them of a stolen soil moisture density gauge (SMDG): Troxler Model 3411 S/N: 5500, Cs-137 and Am:Be-241. (A driver for the licensee) picked up the SMDG from the office to bring to (another employee) and stopped for coffee at the Florida City Quick Stop at 239 SW 344 Street. While inside, the gauge was stolen from the pickup truck with the use of a grinder to cut the cables and locks. Florida City Police Department was called, and (Florida City police officer) responded who filed report number 21001477. (The licensee employee) agreed to submit the most recent copy of the leak test for this gauge. (A BRC inspector will be conducting an investigation). Florida Report Number: FL21-021 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
The following report was received via email from the Florida BRC: (The licensee) has submitted the most recent copy of the leak test for this gauge. The BRC Inspector responded to this incident and the SMDG has not been found. From a discussion over the phone, the lock(s) and chain(s) were really cut into using power tools. (The) Inspector took pictures and obtained some from the licensee. The address for the gas station receipt that the employee gave him does not match the address of the gas station that was reported to the IRC ((Incident Response Coordinator)). The gas station has a camera that faces the parking lot, but did not record the theft. Notified R1DO (Dimitriadis), ILTAB and NMSS Event Notifications via email. |
| ENS 54926 | 1 October 2020 12:03:00 | The Florida Bureau of Radiation Control reported the following via email: The RSO (Radiation Safety Officer) notified the BRC (Bureau of Radiation Control) by mail that a leak test performed on this source (217.6 microCurie Cs-137 e-vial) resulted in greater than 0.005 microCi of the acceptable removable contamination. After determination, the source was sealed within the shielded e-vial container using silicone. The outer shielded container had no removable contamination. The sealed container was then wrapped in plastic. The outer plastic also had no removable contamination. The area was evaluated for signs of removable contamination with no results above background. The licensee intends to dispose of this source through a licensed radioactive waste disposal company. Florida Event Number: FL20-113 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 54782 | 15 July 2020 14:35:00 | The following information was received via E-mail: On 7/15/2020, at 1340 EDT, the licensee reported that yesterday, 7/14/2020, sometime between 0915 and 0930 EDT, a male patient receiving TheraSphere treatment was underdosed by approximately 30 percent due to a leak in the delivery assembly. This was discovered around half-way through the procedure. No exposure to anyone other than the patient occurred. Contamination has been contained and removed. The prescribed activity was 5.7 GBq and dose was 150 Gy. The actual activity delivered is estimated to be 3.99 GBq and dose was 105 Gy. The patient is scheduled to return next week for follow-up treatment. Florida Incident Number: FL20-080 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 54743 | 9 June 2020 16:55:00 | The following was received via email from the Florida Bureau of Radiation: At 1605 (EDT), (on June 9, 2020, the University of Florida) RSO (Radiation Safety Officer) reported a radiation overdose at the Human Use Facility, Jacksonville, FL. The physicists began reviewing the patient's treatments on Friday, June 5, 2020. They were evaluating an Excel spreadsheet used to calculate monitoring units (MUs) for double scatter proton therapy and after 15 fractions caught an error. The intended dose was 80 Gy. At this point in the treatment 30 Gy should have been delivered, but instead the current total is approximately 50 Gy. The treating physician was informed and they informed the patient. It has been concluded that the patient will return to complete treatment and receive in total 59 Gy, which is a commonly used fractionation scheme. The doses to the organs at risk (OARs) are within the tolerance of the treatment goals of the delivered fractionation scheme. They are continuing to review the issue and will send a report as soon as possible. Incident Number: FL20-066 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 54684 | 30 April 2020 15:37:00 | The following information was received from the state of Florida via email: The state of Kentucky Radiation Health (Branch) faxed a report of rejection of an UBC (used beverage can) bale from Logan Aluminum of KY, originating from Republic Services of Jacksonville, FL. The radiation measurement was 1200 cps (also reported as 0.7 mR/hr.) midway of the enclosed trailer. Background measured 121 cps. DOT-SP 10656 KY-FL-20-001 was issued. Per (an employee) of Republic Services, this load was comprised of household curbside waste, and 'people put whatever they want in there.' Only one bale was higher than background. The rest of load successfully resubmitted. Update: This bale was returned to Florida for investigation, whereupon (the Radiation Safety Officer at Republic Services) reached out to the (Headquarters Operations Officer at the Nuclear Regulatory Commission), who transferred him to the BRC (Florida Bureau of Radiation Control). Florida BRC will be conducting a follow-up investigation. Florida Incident Number: FL20-051 |
| ENS 54618 | 26 March 2020 14:25:00 | The following was received via email: (The licensee) notified the (Florida Bureau of Radiation Control) BRC that a Soil Moisture Density Gauge was 'bumped over' at a construction site in (Clearwater, FL) by a machine while in use during a standard count. (The licensee) claims there was no damage to the sources, only damage to the case. The area has been cordoned off, no information on site exclusion prior to the impact has been reported. The (Radiation Safety Officer) RSO has not returned phone calls at this time. The (Florida State Watch Office) FL SWO and (Department of Environmental Protection) DEP have contacted the BRC about this incident. An inspector from (the Florida western office) is requested at this time. Florida Incident Report Number: FL20-045
The following was received via phone call: The gauge was bumped and dragged approximately 10 feet at the construction site during a calibration. The source was retracted. There was no release or visible damage. Notified R4DO (Kellar) and NMSS Events (via email). |
| ENS 54544 | 25 February 2020 18:03:00 | The following was received from the state of Florida via email: On 24 Feb. 2020, at 1315 EST, an underdose of radiation to a patient receiving skin therapy occurred. The patient was scheduled to receive five fractions, at 7.5 grays per fraction, on five different parts of the left hand per fraction. On the first dose of the first fraction, it was observed that catheter numbers 1 - 15 were reversed, causing an underdose to the patient. No Authorized Users were exposed to the source or otherwise contaminated. The licensee has agreed to submit further information on 26 Feb 2020. Since the cause of this incident is machine generated, in accordance with BRC (State of Florida Bureau of Radiation Control) procedures, it is not being given an incident number, and is being forwarded to ERCX (the X-Ray Machine Section of the BRC). 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 54504 | 31 January 2020 14:56:00 | The following was received from the state of Florida Bureau of Radiation Control via fax: (Customs and Border Protection) CBP called the (Bureau of Radiation Control Incident Response Center) BRC IRC to report that at 1105 EST, CBP had a gamma alarm from a fixed radiation portal monitor for a 20 ft. sea container manifested as containing PVC Leather, Buckles, and Grommets. A CBP officer inspected the container using a RadSeeker DL RIID (1.5x1.5in LaBr3). The RIID identified Th-232, and this was confirmed manually by CBP lab personnel using PeakEasy gamma spectroscopy software. The highest reported dose rate was 103 microR/hr at contact with the sea container (1034 cps at contact); this is approximately 9-10 times the average background dose rate for this location. The radiation was distributed throughout the entire length of the container. Guidance requested as to whether or not CBP should refuse entry on the shipment, or if it is acceptable to release it into commerce. There are concerns as to whether or not this product may contain one-twentieth of one percent (0.05 percent) or more by weight of Th-232, violate other radiological regulations, or pose additional concerns. Notified R1DO (Henrion), NMSS Events (email), OIP Notifications Resource (email) Florida Incident Number: FL20-011
This morning between 0800 and 0900 EST, (BRC IRC) inspector went to the Blount Island Marine Terminal in Jacksonville, FL to inspect a container that US Customs and Border Protection had identified as having higher than background levels of radiation. The container was opened for (the inspector), and (the inspector) found the items in the container did match the information that was reported to the Bureau of Radiation Control (BRC). Specifically, spools of faux-leather, and boxes that contained plastic grommets and buckles. These items were manufactured or assembled in China for delivery to a pool cover supply company in Apopka, FL. The boxes did not contain radiation levels above background. The spools of faux-leather had slightly higher than background levels of radiation when unrolled. Their spindles were made of cardboard and did not have higher than background levels of radiation. When the faux-leather was rolled up, the radioactivity increased. The BRC has given the guidance that the container and its contents may be released, but this has not happened yet. If it is released, the BRC is of the opinion that the intended recipient should be surveyed for radiation, in case this is a common occurrence. Notified R1DO (Henrion), NMSS Events (email), and OIP Notifications Resource (email) |
| ENS 54458 | 30 December 2019 17:26:00 | The following is a summary received from the Florida Bureau of Radiation Control via email: The now closed Christ Medical Center facility is involved in bankruptcy and other litigation. The Florida Bureau of Radiation Control could not remove the radioactive material from the facility until assets were settled. The facility is now in contract for purchase. The real estate agent stated that he would open the facility for the Florida Bureau of Radiation inspector to review and determine if the five devices containing radiological material are still present. The Florida Bureau of Radiation inspector will inspect the facility and take custody of the sources. Florida Incident Number: FL19-155 THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 54444 | 13 December 2019 14:50:00 | The following was received from the Florida Bureau of Radiation Control (the Bureau) via email: I-125 therapy seed (243 microCi) was mistakenly incinerated with medical waste. Pathologist mistook metal clip for seed and included it in the material to be incinerated. This information is from a preliminary phone report (to the Bureau); a full written report with radioactive source info will be submitted via email. Incident Number: FL19-148 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 54442 | 13 December 2019 14:39:00 | The following was received from the Florida Bureau of Radiation Control (the Bureau) via email: At (licensee), on or around 1745 EST 22 November 2019, a male patient being treated with Y-90 theraspheres had a blockage on the catheter. The Interventional Radiologist increased the pressure on the line, rupturing the intubation tube. No contamination of staff, only patient. Decontamination of the room and patient followed, no contamination on skin, only gown and tube. Vials were disposed of with waste, so no batch numbers of spheres are available at this time. Problems with imaging occurred, so there are no images at this time. The Radiation Safety Officer (RSO) has asked for reports with more information from Interventional Radiologist (IR) and Radiation Oncologist Authorized User (ROAU). IR and ROAU disagree on how much activity the patient received before the rupture; patient was prescribed 15 mCi. Patient will return for further treatment. The Bureau has been notified and an inspector will be assigned to investigate. Incident Number: FL19-141 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 54259 | 6 September 2019 12:44:00 | The following report is a synopsis of an email received from the Florida Bureau of Radiation Control (BRC): On September 6, 2019, Westrock CP, LLC called to notify the BRC of a lost Cs-137 source (serial number: S99J2804). The activity of the source as measured on approximately January 1, 1997, was 5 mCi. Westrock had planned to remove five sources during a semi-annual inventory survey, but they were unable to locate one of the sources. A more sensitive survey meter was then flown to the licensee, but it was unable to detect any activity in the area where the source was expected to be. Florida Incident Number: FL19-111 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 54260 | 6 September 2019 13:59:00 | The following report is a synopsis of an email received from the Florida Bureau of Radiation Control: During an inventory conducted on August 2, 2019, the University of Florida discovered that a Ni-63 source was improperly sent to a scrap metal processor. The Ni-63 source (serial number: 3270) had an activity of 13.5 mCi. Florida Incident Number: FL19-098 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 54082 | 23 May 2019 16:55:00 | The following information was obtained from the state of Florida via email: On May 22, 2019, (the licensee Radiation Safety Officer) notified the BRC (Florida Bureau of Radiation Control) of an overdose of radiation treatment to a female 60 year-old Caucasian patient. Patient was prescribed ten 340 cGy planning target volume (ptv) fractionated treatments: 2 per day for 5 days. Minimum dose of 340 cGy per fraction, mean dose value 625 cGy per fraction, actual dose administered 1167.3 cGy in single fraction. Source S/N: 24-01-7403-001-032119-13092-68. Licensee has notified the patient that an overdose did occur, and expects no harm to the patient due to this fraction of treatment. Patient has five more treatments. The machine used was a Varying GammaMed+, SN 641053, using a 7.385 Ci Iridium-192 GammaMed 232 source. Florida Incident number: FL19-071 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 53748 | 20 November 2018 16:04:00 | The following information was received via e-mail from the State of Florida: On Friday, November 16, 2018, (the licensee) called to report a medical event involving licensee 4000-1. A patient was administered 150 milliCi of Sodium Pertechnetate that was originally intended to be used to calibrate a machine. The critical organ dose was less than 50 rem; the effective dose was 7 rem. 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 53720 | 7 November 2018 15:44:00 | The following information was received by the State of Florida: At noon (on 11/7/18), (Akumin) called (the State of FL Bureau of Radiation Control) to report that both Akumin Hollywood and Akumin Aventura View ordered F-18 Fluciclovine, and received packages that were labeled as F-18 Fluciclovine, but were subsequently notified by their radiopharmaceutical vendor PET NET Solutions-Ft Lauderdale, on Thursday, November 1, 2018 that due to a 'batch error,' the packages actually contained F-18 FDG (Fludeoxyglucose). Three patients were reported as receiving the incorrect radiopharmaceutical. Activity reported as approximately 10 mCi. Florida Incident: FL18-137 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. |