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| Entered date | Event description | |
|---|---|---|
| ENS 56746 | 19 September 2023 13:03:00 | The following information was received from the Colorado Department of Public Health and Environment via email: After completing a Yttrium-90 TheraSpheres treatment, (medical personnel) were measuring the residual Yttrium-90 TheraSpheres and found that the administered dose delivered to the patient was only 313.2 Gray and the prescribed dose was 407 Gray. The total dose delivered was only 77 percent of the prescribed dose. The department is investigating the cause of the event. Colorado Event Report ID: CO 230032 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 56397 | 9 March 2023 11:16:00 | The following information was provided by the Colorado Department of Public Health and Environment (CDPHE) via email: At approximately 1400 MST on March 7, 2023, while performing a meta-iodobenzylguanidine (MIBG) infusion of 266 mCi of I-131 in a patient at Children's Hospital Colorado, an unplanned contamination event occurred on the floor of the hot lab. The floor contamination was discovered at approximately 1730 MST on March 7, 2023, by the licensee. The hot lab has been secured from entry. The licensee believes the amount spilled is greater than 5 times the annual limit on intake (ALI). CDPHE will be receiving more information from the licensee. The licensee will be performing bioassay soon and will provide more information at that time. Colorado Event Report Number: CO 230006 |
| ENS 56442 | 30 March 2023 16:18:00 | The following information was provided by the Colorado Department of Public Health and Environment via email: A customer shipped a package containing an AirSentry II-IMS unit with a 10 mCi nickel-63 source to Particle Measuring Systems. On February 16, 2023, the customer emailed that the package should have arrived. Particle Measuring Systems contacted the common carrier, whose tracking system showed the package was delivered on February 7, 2023. The site conducted an extensive search but could not locate the package. The Radiation Safety Officer was informed on March 1, 2023, that the package was lost. The Colorado Radioactive Materials Unit was subsequently notified of this event on March 10, 2023. Colorado Event Number: CO 230009 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 56195 | 1 November 2022 14:05:00 | The following information was received via email from the Colorado Department of Public Health and Environment (the Department): During the afternoon of 10/31/22, an InstroTek model 3500 portable gauge was found by a member of the public and turned into Radiation Pros, LLC (specific license CO 1183-01). The isotopes are presumed to be 11 mCi cesium-137 and 44 mCi americium-241:beryllium, but the Department is awaiting confirmation. Radiation Pros, LLC contacted the Department to let us know that they have the InstroTek model 3500 on site and that they contacted InstroTek with the serial number of the portable gauge to find out who owned the gauge. InstroTek let Radiation Pros know that the gauge belongs to Geostruct Engineers, Inc. dba RMG-Rocky Mountain Group, radioactive material license number CO 758-01. Radiation Pros contacted Geostruct Engineers and let them know that they have the portable gauge. Geostruct Engineers picked up the InstroTek portable gauge and transported it back to the licensed location. This event appears to be unrelated to Colorado event CO210032 (EN 55510). Colorado Event Report ID No.: CO 220036 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 54980 | 3 November 2020 11:27:00 | The following is a summary of information received from the Colorado Department of Public Health and Environment: The licensee reported that an InstroTek 3500 moisture/density gauge was stolen from the licensee's truck at 0730 MST on 11/3/20. The gauge was secured in the truck, and the truck was parked near the gauge user's house when the gauge was stolen. The police have been notified of this event. Sealed Sources: 11 mCi of Cs-137 and 44 mCi of Am-241:Be Event Report ID No.: CO 200063 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 54240 | 26 August 2019 15:26:00 | The following is a summary received via email from the state of Colorado: On August 26, 2019 at 11:13 MDT, the Colorado Department of Public Health and Environment was notified by Ninyo & Moore, that Troxler 3430 moisture density gauge with 9 mCi source of Cs-137 and 44 mCi source of Am/Be was stolen from Colorado School of Mines in Golden, Colorado. The Troxler gauge was last seen on August 23, 2019. Campus police were notified and they have put out a state wide notification informing state police of the missing gauge. Event Report Number: CO 190016. 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 |