Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 56853 | 14 November 2023 16:54:00 | The following information was provided by the Florida Department of Health via email: On 11/14/2023, a patient arrived in the nuclear medicine department for administration of their fourth cycle of Lutathera, a Lu-177 labeled radiopharmaceutical. The standard prescription of Lutathera for patients is 200 mCi in accordance with manufacturer's instructions for use and industry standard. The technologist assayed the vial and went through pre-administration procedures including a pre-treatment time out. 202 mCi of Lutathera was administered via IV in the right upper forearm over the course of thirty minutes. Start time of 1211 (EST) with an end time of 1241. Upon completion of the procedure, the technologist noticed that the patient had been prescribed a reduced activity of 150 mCi as opposed to the standard prescription of 200 mCi. Realizing this was a medical event, the technologist notified the radiation safety officer (RSO) at approximately 1330. The technologist also informed the nuclear medicine department supervisor. The RSO proceeded to inform the Authorized User (AU)/prescribing physician. The AU spoke with the patient explaining that the activity administered exceeded the prescribed amount. The physician explained that he did not expect any adverse effects from the higher than prescribed activity as the patient had received the standard activity of 200 mCi. The reduced activity of 150 mCi had been decided by the prescribing physician due to borderline renal function and the patient had tolerated all previous three administrations. Since the patient's renal function was not affected by the three previous administrations, the prescribing physician explained that the patient could have received the 200 mCi. The patient did not express concern upon being informed of this event. The AU also informed the referring physician. An initial report was made to (Florida) via telephone at 1529 in accordance with 64E-5.345(4)(a). Florida Incident Number: FL23-164 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 56074 | 27 August 2022 21:51:00 | The following information was provided by the state of Florida via email: (The licensee's Radiation Safety Officer) (RSO) called at 1946 EDT to report a stolen Troxler Soil Moisture Density Gauge. The Pacifica technician found the chain and padlock were cut. The initial discovery was at approximately 0830 EDT, but was not reported to the RSO until later in the day. When asked why the incident was reported nearly 12 hours later, (the RSO) stated that the technician had a morning exam, and that he was afraid of losing his job. Additionally, since (the RSO) had not notified Law Enforcement at the time of his report, he was instructed to do so. Finally, (the RSO) was instructed to email this (Florida Bureau of Radiation Control) Duty Officer with the report number, along with his description of the event. Incident number: FL22-099 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 55719 | 31 January 2022 16:05:00 | The following is a synopsis of an email received from the State of Florida: (RSO) called and reported that a Nuclear Moisture Density Gauge fell out of the back of his pickup truck while traveling/transporting the gauge from the office to a work site at SR 64 and Dam Rd. The gauge was padlocked in its case and chained on each side of the case to eyelets in the back of the truck using padlocks to secure the chains. Upon arrival at the worksite (Manatee County) the truck tailgate was open and the gauge was missing. The padlocks securing the chains were broken. (RSO) retraced his travel route two times to look for the missing gauge. The gauge was NOT found. (The RSO) reported the incident to both the Manatee County's and Sarasota County's Sheriffs Departments. Sarasota County Sheriff Dept. Case number 22-8695 was issued. Report identified the sources to be Cesium-137 (10 milliCuries) and Americium-241/Be (50 milliCuries). Florida Incident Number: FL22-012 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 55496 | 28 September 2021 13:45:00 | The following is summary of an event received from the state of Florida via email: A Cs-137 source (184.3 microcuries) was discovered missing at the Reception and Medical Center (RMC) of the Lake Butler Nuclear Medicine Department, at the Lake Butler Department of Corrections (DOC). The medical center is contracted to operate under Jacksonville Cardiovascular Center. The building is a modular trailer. The missing source was noted during a scheduled inventory. The source is believed to have been moved or relocated by the DOC during construction to repair a collapsed floor. The source is believed to be somewhere in the trailer. Florida Incident Number: FL21-122 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 55110 | 21 February 2021 22:52:00 | Florida Bureau of Radiation Control (BRC) provided the following initial report via email: (A) Department of Health Regional Emergency Management (EM) Supervisor reported a call from Walton County EM advising of potential hazardous materials at a private residence in Defuniak Springs. Caller stated that several containers appear to be medical materials discovered in a storage shed near the residence. The containers are marked with a "radiological material" symbol. Local Fire Rescue (FR) and Walton County Sheriff's Office (SO) are on scene and Bay County FR has their HazMat unit in-route. Florida Incident Number: FL-21-025 The following is a synopsis of the post HAZMAT investigation report: The material was discovered in a storage shed on a rented property nearby. The renter does not know how long the material had been there or where it originated. Personnel at the scene were surveyed. No contamination was revealed. Detailed investigation of the material showed no leakage. Only one lead pig registered slightly above background radiation. The source within the pig was determined to be Thorium-232 'hot source' in a sealed vial. The vial was not leaking. BRC took possession of the Thorium source. Hazmat took possession of the remainder of the material. Area was cleared at 0015 EST, 22 February 2021. |
| ENS 55090 | 29 January 2021 16:38:00 | The following was received from the Florida Bureau of Radiation Control (BRC) via email: The (licensee) reported a failed leak test of a cesuim-137 (activity 197.2 microcuries - January 1, 2006) `E' vial. The test was conducted January 27, 2021. The leaking source has been double-bagged and is being stored in a lead-shield container while awaiting an investigation and eventual transfer for disposal. No detectable contamination was found in the storage area, on personnel, in work spaces, nor on equipment. A formal report is forthcoming. The BRC has been contacted and tasked to investigate. Florida Incident Number: FL21-013 |
| ENS 54450 | 17 December 2019 22:42:00 | The following was received from the Florida Department of Health via email: (The Radiation Safety Officer (RSO)) reported an incident involving a damaged Troxler Soil Moisture Density Gauge. The 2 sources (Cs-137 (8 mCi); Am-Be (40 mCi)) were not damaged or dislodged. The only damage was to the operator handle. At approximately (1450 EST), the gauge was bumped by a bulldozer (at a temporary work site in Ocala, FL), damaging the handle. The gauge is repairable. (The RSO) will follow-up his initial report with a written report on Wednesday, December 18, 2019. No further action is required. Event Incident Number: FL19-151
The following was received from the Florida Department of Health via email: The sources are currently in the licensee's possession. The State will dispatch an inspector for this incident and pictures of the gauge, a leak test, and a report including corrective actions taken to prevent re-occurrence will be required. Notified R1DO (Werkheiser) and NMSS Events (email). |
| ENS 53567 | 27 August 2018 13:11:00 | The following information was obtained from the state of Florida via email: Ardaman & Associates, Inc., reported to (the Florida Bureau of Radiation Control) a damaged Troxler Gauge at Lake Brantley High School, 991 Sand Lake Rd, Altamonte Springs, FL 32714. Gauge was backed into by heavy equipment. Sources were not extended at the time, and are not damaged. All radiation readings taken after damage were normal expected values. The gauge was immediately retrieved and removed from work site. Gauge is being transferred to Troxler Orlando Office for evaluation and determination for repair or replacement. The gauge contained an 8 mCi Cs-137 source and a 40 mCi AmBe-241 source. Florida Incident No. FL18-112 |
| ENS 53415 | 21 May 2018 21:49:00 | Received the following by email from Florida Bureau of Radiation Control. (A) resident at Waterford (Senior Living Center), recently passed away. His son contacted a licensed Firearms Dealer and Estate Appraiser, to assess his father's estate value. (The appraiser) discovered a metal canister containing a grayish-silver marble-sized sphere. A certificate in the (deceased's) personal effects states that the sphere is Pu, and is a gift given in appreciation of the (deceased's) contributions to The Manhattan Project. Also included in the (deceased) personal effects is a piece of glass said to be from Atomic Bomb Testing. The Certificate is signed by Robert Oppenheimer. (The Estate Appraiser), contacted the ATF. The ATF Special Agent contacted the Bureau of Radiation Control (BRC) Duty Officer. A preliminary investigation is scheduled for Tuesday, May 22, 2018. Florida report # FL18-062.
Phone conversation with appraiser and son revealed the following: Deceased passed away years ago, and his wife, who has had her spouse's possessions since then, is moving from the Senior Center. Their son was given the name of an Estate Liquidator, to assess their belongings. The appraiser came across a metal shoe shine sized canister containing what he described as marble sized pellets and sandy glass, that had Plutonium marked on it. There also was a framed Reference letter addressed to the deceased from Robert Oppenheimer, thanking him for his contributions to The Manhattan Project. Unbeknownst to the son, the appraiser then contacted the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) with his concerns. The son stated that the material in the canister was fused sand from the Trinity test site, and did not know why the appraiser was concerned about it. Florida report # FL18-062. Notified R1DO (Dimitriadis), IRD MOC (Pham), and NMSS Events Notification (email). |
| ENS 53417 | 22 May 2018 16:45:00 | Received the following notification from Florida Bureau of Radiation Control. Sun Nuclear Corporation's RSO, contacted Florida Bureau of Radiation Control to report a WB (Luxel) badge report received from Landauer (global dosimetry solutions) indicating an exposure to a Sun Nuclear employee of 6.6 REM. The RSO believes Landauer mixed-up the badges and incorrectly reported the exposure on an individual's exposure record. A different employee's badge had been left in the calibration room overnight. That badge exposure reading was recorded at a normal exposure level. The RSO contacted Landauer about the situation: Landauer is conducting an internal review. The RSO is currently conducting an internal review and investigation at Sun Nuclear. Florida Bureau of Radiation Control Environmental Manager, has been notified, and will assign an inspector to investigate. Florida report # FL-18-064 |
| ENS 53421 | 23 May 2018 11:25:00 | The following report was received from the State of Florida via email: The (Bayfront HMA Medical Center) RN (Registered Nurse) called FDOH/BRC/ERCM (Florida Department of Health, Bureau of Radiation Control, Environmental Radiation Control Materials) (Tallahassee - Licensing & Enforcement), to report that she was exposed to I-131 following patient urination during that patient's care. (The RN) was informed that she received a POSITIVE bioassay subsequent to the exposure event. Her shoes were impounded for decay. Other employee bioassays conducted were NEGATIVE. (The RN) reported that she DID NOT conduct urine clean-up during the patient care. The RSO (Radiation Safety Officer), was called, and a VM (Voice Mail) was left requesting a return call. (A State of Florida Bureau of Radiation Control Inspector) was called and directed to conduct an investigation. FL Incident Number: FL18-065
Incident occurred May 10 following Thyroid Ablation (150mCi I-131); RN bioassay performed following week; results slightly greater than background. Bioassay & dosimetry results to be forwarded. |
| ENS 51833 | 30 March 2016 16:05:00 | The following information was received from the State of Florida via email: A Troxler Gauge was run over by heavy equipment at a construction site. The Type B container case was broken open exposing the source. (A Florida State) Inspector was sent to the scene to investigate. State of Florida Incident Number: FL16-047 |
| ENS 51626 | 29 December 2015 13:36:00 | EN Revision Imported Date : 9/29/2020 AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE The following report was received from the State of Florida via email: At approximately 0800 (EST), a construction 'con-x box' was found with a padlock and chain cut off. The Troxler Gauge Model No. 3440, Ser. No. 70830 was found missing. The incident was immediately reported to (the licensee Radiation Safety Officer), who reported the incident to BRC (Bureau of Radiation Control). (The licensee Radiation Safety Officer) reported the theft to law enforcement. The gauge contains 8 mCi of Cs-137 and 40 mCi of Am-241/Be.
The following is a summary of an email received from the State of Florida: The Bureau of Radiation Protection (BRP) was notified on September 28, 2020, that the gauge was listed for sale on Ebay on September 23, 2020 from Hialeah, FL, and is still listed. BRP contacted the Hialeah Police Department. Notified R1DO (Arner), NMSS Events Notification, and ILTAB via email. Incident Number: FL15-135 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 49964 | 27 March 2014 10:16:00 | The following was received from the State of Florida via email: Y-90 Sir-Sphere injection delivered 62% of prescribed dose. Licensee or Owner is currently unknown. Radiation Services, Inc. (RSI) is a Medical Physics Consulting firm. This event was reported to RSI by a client as a request for consult. RSI did not perform the procedure. No other information is know at this time. Florida Incident Number: FL14-026 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. |