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| Entered date | Event description | |
|---|---|---|
| ENS 53516 | 19 July 2018 02:04:00 | The following information was obtained from the state of California via email: A cervical patient was receiving her first High Dose Rate (HDR) brachytherapy treatment, using the Varian VariSource iX HDR, on Tuesday, July 17, 2018, starting at 10 am (PDT). The patient's 3 applicators, for the tandem and right/left ovoids, were attached to the distal ends of the transfer guide tubes specially coded for the GYN treatments (using the Varian Quick Fit connectors), with the tandem as channel 1, ovoid right as channel 2 and ovoid left as channel 3. The guide tubes were attached by the radiation therapist, and checked by two other employees. After the first fraction, the radiation therapist was preparing to disconnect the guide tubes from the applicators and noted that the distal end of the transfer guide tube for channel 1 was hanging approximately vertically along the end of the gurney. The physicist also verified this, and that the Quick Fit connectors for all of the guide tubes were still secured to the applicator and locked in place with their locking rings. However, it appeared that the transfer tube for channel 1 had been severed at its distal end from its Click Fit connector. The patient was re-surveyed to confirm that the source had retracted appropriately, with no radiation detected within the patient. The radiation therapist proceeded to disconnect the guide tubes from the applicators, remove the applicators from the patient, and clean the patient up for discharge home. The licensee is unable to ascertain whether the tube failed before the Ir-192 source deployed to the treatment site or upon return of the source to HDR storage. It is possible that the patient received the planned treatment, with the source in the correct dwell locations. It is also possible that the Ir-192 seed landed on the gurney close to the patient's skin, or that the source extended vertically down from the distal end of the transfer tube, in which case the patient's lower extremities were exposed to a smaller dose of approximately 500 mR. Staff immediately notified Varian of the event, and took the tubing out of service. New tubing is scheduled to arrive on Friday 7/20/2018, and no HDR treatments will occur before then. Staff also immediately notified the patient's physician. RHB will conduct a site visit on Friday 7/20/2018. California report no.: 5010-071718 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 53450 | 9 June 2018 10:48:00 | EN Revision Text: AGREEMENT STATE REPORT - INCORRECT DOSE ADMINISTRATION The following report was received from the State of California by email: (The) National Director Medical Physics, of McKesson Specialty Health, Radiation & Imaging, contacted LA County Radiation Management (LA County) on June 8, 2018 to report a potential Medical Event that occurred at Western Tumor Medical Group on May 9, 2018. The National Director Medical Physics has been remotely reviewing available data at their location in Decatur, Georgia, and while they are not able to definitively conclude the unplanned dose to the patient's small intestine/bowel pending the return of the Western Tumor Medical Group RSO from overseas, it appears that a Medical Event occurred. The potential Medical Event occurred during an HDR (High Dose Rate) brachytherapy procedure in which the tandem ovoid insert shifted inside of the female patient's pelvis (which has extensive damage from uterine cancer) apparently causing two of the dwells to shift to a position different from that in the treatment plan. As a result, the dose to the non-target small intestine/bowel from the 1st of 3 fractions is believed to have been about 587 cGy (587 rad), instead of the planned approximately 220 cGy (220 rad). The treatment plan was modified for the shifted tandem ovoid position, and the 2nd and 3rd fractions were given resulting in approximately 220 cGy (220 rad) each to the small intestine/bowel. A site visit will be conducted to meet with the licensee's personnel when the RSO comes back from travel to gain a better understanding of the details of the event, including the delay in the reporting of the event by the RSO, and patient/patient's physician notification.
The following information was received from the State of California via email: Calculations have been performed by the Licensee's RSO that demonstrated to (the State of California) that (the dosage) fell below the reportability threshold of 10 CFR 35.3045(a)(1) and 35.3045(a)(3) because the dose occurred to the non-target organ, and only in the first of the 3 fractions, causing the numbers to even out, i.e., average down to below reportable numbers (in terms of 50 REM and 50% of planned dose). California ID # 060818 Notified the R4DO (Deese) and NMSS Events Notifications via 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 53281 | 22 March 2018 21:47:00 | The following is a synopsis of information received via E-mail from the State of California: On March 22, 2018 the Director of Environmental Affairs at NBC Universal (i.e. Universal Studios) in Universal City, California called Los Angeles County Radiation Management to report the discovery of a broken Tritium exit sign. The Tritium sign was subsequently isolated for secure and safe keeping. A Los Angeles County Radiation Management employee will visit Universal Studios on March 23, 2018 to check for Tritium leakage or contamination. The broken sign is a Forever Lite Inc. Tritium sign, S/N 286342, with an expiration date of March 2027, containing 11.21 Curies. California 5010 Number: 032218 |
| ENS 52559 | 16 February 2017 21:43:00 | The following information was received from the State of CA via email: (The) President of CPN InstroTek in North Carolina called Thomas G. Miko of Los Angeles County Radiation Management, the LEA for Radiologic Health Branch (RHB), on February 16, 2017, from his office in North Carolina. (The CPN President) received a phone call from an anonymous caller in California who found a nuclear gauge from CPN InstroTek. The anonymous caller told (the CPN President) that the gauge is in a shed on a ranch in Southern California. (The CPN President) provided the anonymous caller's cell phone number. Thomas G. Miko spoke with the anonymous caller at 4:30 p.m. on February 16, 2017. The anonymous caller stated that he is in Palm Springs, and that the gauge is in a storage shed of items removed from a pawn shop in Temecula, California, after it went out of business. He said that this shed is in Desert Hot Springs, California, outside of Los Angeles County's jurisdiction. Arrangements were made with the anonymous caller for him to drop off the gauge in its original case at the Riverside County Fire Station, where he would contact (a designated) Firefighter. (The CPN President) requested that Radiologic Health Branch provide him with the serial number of the gauge for his own reference, once Radiologic Health Branch employees take possession of the gauge from Riverside County Fire Department. Arrangements were made for (a) Radiologic Health Branch employee to drive from the Brea, Orange County, California office to take possession of the device from Riverside County Fire Department on Friday, February 17, 2017. RHB Brea will follow up to see if they can match the gauge's serial number with that of any previously reported lost or stolen gauges. CA 5010 Number: 021617
The missing gauge was not in the case. Law Enforcement is conducting an investigation. Notified R4DO (Gepford), NMSS (McIntosh) and ILTAB (Pearson).
The State of California is retracting this report since no gauge was identified or recovered. Notified R4DO (Gepford), NMSS (McIntosh) and ILTAB (Pearson).
The missing radiological source was returned tonight (2/21/17) and is currently at a fire station in Riverside County. The gauge will remain at the station overnight and will be picked up by California Department of Public Health, Radiologic Health Branch tomorrow (2/22/17). Notified R4DO (Pick), ILTAB (Whitney) and NMSS (McIntosh). 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 52463 | 28 December 2016 19:11:00 | The following report was received via email: On December 28, 2016, the Hazardous Materials (Manager) at NBC Universal i.e. Universal Studios in Universal City, California called Los Angeles County Radiation Management on the telephone to report the loss of two Tritium exit signs. As of December 28, 2016, the Los Angeles County does not have information regarding the make, model, or serial numbers of the missing exit signs, or the quantity of H-3 (Tritium) in them. CA 5010 Number: 122816 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 update was received via email: On January 10, 2017, (the licensee's) Manager of Hazardous Materials at NBC Universal (i.e. Universal Studios in Universal City, California) reported to Los Angeles County Radiation Management by email that they have found the two Tritium exit signs that our agency reported to (the NRC) on December 28, 2016 (California 5010 # 122816). As of January 25, 2016, Los Angeles County does not have information regarding the make, model, or serial numbers of the missing exit signs, or the quantity of H-3 (Tritium) in them. (The State of California Los Angeles County Radiation Management) has requested this information from (the licensee), again, today. When (the Licensee) provides this information, it will be included in the California 5010 close-out. The NMED number for this event is 170010. Notified the R4DO (Rollins) and NMSS_Events_Notification via email. |
| ENS 51866 | 15 April 2016 15:00:00 | The following information is a summary of the information received from the State of California: On April 11, 2016, a City of Los Angeles garbage route truck alarmed the radiation monitors at the Athens Waste Services Sunland transfer station. The transfer station supervisor notified the California Department of Health - Radiologic Health Branch. The State dispatched an inspector to the facility. Upon arrival, the inspector was notified that the truck had returned to the City of Los Angeles East Valley Complex. The inspector travelled to the East Valley Complex. Upon arrival at the East Valley Complex, where the truck had been isolated, the inspector was able determine the approximate location of the device in the rear of the truck. The inspector was informed that a crew was not available to dump the contents to search for the item at that time. Arrangements were made for the inspector to return when a crew was available. The truck remained isolated. On April 14th, the inspector returned to the East Valley Complex to search for the source. A crew was assembled and the contents of the truck were dumped. Using a survey meter, the inspector was able to locate a 2.61 mCi Ra-226 radiation oncology treatment needle. No other sources or radioactive devices were discovered. The inspector secured the source in a lead pig and placed it into the State's inventory. Prior to the removal of the source, the highest radiation reading outside the truck was 1.2 mR/hr. on contact. California Report number: 5010-041116 |