ENS 54550: Difference between revisions
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{{ENS notification | {{ENS notification | ||
| event number = 54550 | | event number = 54550 | ||
| facility = | | facility = | ||
| Organization = Georgia Radioactive Material Pgm | | Organization = Georgia Radioactive Material Pgm | ||
| license number = GA 1340-1 | | license number = GA 1340-1 | ||
| Line 10: | Line 10: | ||
| utype = | | utype = | ||
| cfr = Agreement State | | cfr = Agreement State | ||
| emergency class = | | emergency class = Non Emergency | ||
| notification date = 02/28/2020 06:54 | | notification date = 02/28/2020 06:54 | ||
| notification by = Gregory Reese | | notification by = Gregory Reese | ||
| Line 19: | Line 19: | ||
| event text = The following is a summary of emails received from the Georgia Department of Natural Resources (the state): | | event text = The following is a summary of emails received from the Georgia Department of Natural Resources (the state): | ||
On 01/18/2019, the licensee performed a Radioactive Seed Localization (RSL) using 81 microCi of I-125. The tissue and seed were transported to pathology where the pathologist misidentified the seed as a straight clip-non-radioactive and the material was designated for disposal. | On 01/18/2019, the licensee performed a Radioactive Seed Localization (RSL) using 81 microCi of I-125. The tissue and seed were transported to pathology where the pathologist misidentified the seed as a straight clip-non-radioactive and the material was designated for disposal. | ||
The Nuclear Technologist realized on 02/06/2019, through paperwork, that the seed could not be accounted for and had improperly gone out through the ordinary waste process at the hospital. | The Nuclear Technologist realized on 02/06/2019, through paperwork, that the seed could not be accounted for and had improperly gone out through the ordinary waste process at the hospital. | ||
On 03/04/2019, the state's reactive inspection report found that the RSL procedure was a two seed implantation. A documentation problem occurred when two separate I-125 seed tracking documents were used instead of one. When the tissue containing the seeds was excised and taken to pathology in a cup, only a single document showing one seed implant made it to pathology. The second document did not arrive, so pathology was unaware that there were two seed implants. This led to one of the seeds being mistaken for a clip. The cup that the tissue was transported in was surveyed at pathology and there was the expected readout, which was attributed to a single seed. | On 03/04/2019, the state's reactive inspection report found that the RSL procedure was a two seed implantation. A documentation problem occurred when two separate I-125 seed tracking documents were used instead of one. When the tissue containing the seeds was excised and taken to pathology in a cup, only a single document showing one seed implant made it to pathology. The second document did not arrive, so pathology was unaware that there were two seed implants. This led to one of the seeds being mistaken for a clip. The cup that the tissue was transported in was surveyed at pathology and there was the expected readout, which was attributed to a single seed. | ||
Corrective actions include to document seeds acquired for implantation on a single sheet of paper. | Corrective actions include to document seeds acquired for implantation on a single sheet of paper. | ||
Efforts were being made to discontinue the RSL program and replace it with a radiofrequency seed localization system that involves no radioactivity. | Efforts were being made to discontinue the RSL program and replace it with a radiofrequency seed localization system that involves no radioactivity. | ||
The incident was closed on 03/04 2019. | The incident was closed on 03/04 2019. | ||
Incident Report No.: GA-2019-10 | Incident Report No.: GA-2019-10 | ||
THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL | 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 | 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 | ||
| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200310en.html#en54550 | | URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200310en.html#en54550 | ||
}} | }} | ||
{{ENS-Nav}} | {{ENS-Nav}} | ||
Latest revision as of 12:51, 15 January 2021
| Where | |
|---|---|
| Georgia Radioactive Material Pgm Fayetteville, Georgia (NRC Region 1) | |
| License number: | GA 1340-1 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+9745.9 h406.079 days <br />58.011 weeks <br />13.35 months <br />) | |
| Opened: | Gregory Reese 06:54 Feb 28, 2020 |
| NRC Officer: | Ossy Font |
| Last Updated: | Feb 28, 2020 |
| 54550 - NRC Website | |