The following information was provided by the licensee via telephone and email:
Two clinical doses of Xofigo [(radium (Ra-223) dichloride, 119 microcuries)] were delivered to the Nuclear Medicine department on 3/31/2022. A patient scheduled for one of the doses on Thursday 3/31/2022 was successfully administered with the activity. A second patient was scheduled to receive the second dose on 4/1/2022 at 1300 EDT.
At scheduled time, the Nuclear Medicine technologists could not locate the second dose. After a thorough search, the RSO [(Radiation Safety Officer)] was notified. It is suspected that the second dose was accidentally disposed of in the box in which both doses were received.
The first dose was properly disposed of in a radioactive sharps container, and the second dose remained in the delivery box within the secured hot lab area. It is suspected that a nuclear medicine technologist threw the box away without realizing a second dose was inside, as it is an extremely rare occurrence for two doses to be delivered concurrently. The dose was not detected during the end of day survey nor by portal monitoring at the waste facility, due to the relatively low activity and low yield of x-rays/gamma-rays (Ra-223 is primarily an alpha emitter).
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