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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 42851 | 20 September 2006 05:00:00 | Agreement State | Irradiator Source Temporarily Stuck in the Exposed Position | On the night of 8/28- 8/29/2006 the large irradiator was being used for an all night procedure. The principle investigator for the irradiator was present to conclude the operation on the morning of August 29. At the time designated for source retraction, the irradiator source in fact did not retract to the stowed position. The source actuation system uses air pressure to expose the source and spring force to stow the source. The principle investigator tried to house the source by operating the "override" button. The source remained exposed. After approximately 15 minutes the source returned to the housed condition with no operator action. The irradiator will not be used until J.L. Shepard (the manufacturer) is contacted and the cause identified and corrected. The source is currently stowed. The irradiator is an 8800 Curie Cs-137 self shielded irradiator. Iowa event number I806004 The state notified Region 3 (Lynch).
The following updated information was called in by the State of Iowa Department of Public Health: The irradiator type is an open beam irradiator. The irradiator has been repaired, tested and placed back in service on 09/21/06. R3DO (Julio Lara) and NMSS EO (Cindy Flannery) notified. | ||
| ENS 43639 | 1 February 2005 05:00:00 | Agreement State | Agreement State Report - Dose Differs by Greater than 50% of Prescribed | The State provided the following information via email: A teletherapy patient received a dose greater than 50% of the prescribed fractionated dose due to an improperly calculated dose delivery time. The medical physicist used a fractionated dose of 200 cGy instead of the prescribed dose of 100 cGy. This overexposure occurred during the first fraction to the patient. Before the second scheduled treatment, a different therapist questioned the long treatment time and brought the matter to the medical physicist. The physicist checked the calculations, discovered the error and cancelled the treatment for the day. The radiation oncologist anticipates no unusual acute or late effects from the delivered dose. The University of Iowa no longer is in possession of this device. It was de-sourced on November 16, 2005. The device was a sealed Co-60 teletherapy source. The therapy was targeting the bone marrow. Iowa report number: IA070003 | ||
| ENS 46458 | 29 November 2010 06:00:00 | Agreement State | Agreement State Report - Leaking Source in a Static Eliminator | The following report was received via e-mail: The following report was received by the Iowa Department of Public Health (IDPH) on December 3, 2010. On November 29, 2010, the University of Iowa Environmental Health and Safety (EHS) staff discovered evidence that a Nickel-63 foil in a custom made static eliminator had lost its seal integrity. The source in question consists of two 10 mCi Ni-63 foils that are housed in a custom built static eliminator (2 inch diameter steel pipe with the foils glued to the walls of the pipe). The static eliminator is attached to a chamber apparatus located in a fume hood within a principal investigator's lab. The results of the leak test indicated approximately 11,500 dpm (0.0052 microCuries) of activity on a wipe taken of several areas in the apparatus housing the Ni-63 foils. EHS personnel bagged the static eliminator and returned it to EHS for disposal. Iowa Report Number: IA100008 | ||
| ENS 46648 | 22 February 2011 06:00:00 | Agreement State | Agreement State Report - Static Eliminator Source Seal Integrity Lost | The following report was received by the Iowa Department of Public Health (IDPH) on February 23, 2011. On February 22, 2011, the University of Iowa Environmental Health and Safety (EHS) staff discovered evidence that a Nickel-63 foil in a custom made static eliminator had lost its seal integrity. The source in question consists of two 8.951 mCi Ni-63 foils that are housed in a custom built static eliminator (2 inch diameter steel pipe with the foils glued to the walls of the pipe). The static eliminator is attached to a chamber apparatus located in a fume hood within a principal investigator's lab. The results of the leak test indicated approximately 40,203 dpm (0.0181 uCi's) of activity on a wipe taken of several areas in the apparatus housing the Ni-63 foils. EHS personnel bagged the static eliminator and returned it to EHS for disposal. The two Ni-63 sources were purchased from DuPont/Merck in March of 1995. The Principle Investigator (PI) had been conducting research using these sources since that time. The University RSO reports that the PI does not have any more of these custom devices and will be pursuing other options for research. A previous leaking Ni-63 foil was reported as NMED Item Number 100592. Iowa Incident No. 110002 | ||
| ENS 55123 | 3 February 2021 06:00:00 | Agreement State | Lost P-32 Shipment | The following was received from Iowa Department of Public Health via email: On February 3, 2021, the University of Iowa received a package from (the common carrier) that was labeled as one of the standing orders of 1 millicurie P-32 dCTP for the Pathology Lab at UIHC ((University of Iowa Health Care)). The outer label was correct and the packing slip inside was correct, however the contents of the package was actually a prescription of Enbrel intended for an individual in Illinois. Further, the contents had obviously been repacked. It arrived in a large (common carrier) box, much bigger than required for the P-32 order or the Enbrel. Also, the top of the original package that held the P-32 had been torn off and affixed to the replacement box in an adhesive pouch. The licensee contacted both (the common carrier) and the pharmaceutical company that shipped the Enbrel. (The common carrier) returned to retrieve the Enbrel but haven't heard anything about the location of the original P-32 order. Perkin Elmer sent a replacement shipment of P-32 to the licensee. On February 10, 2021, (the common carrier) sent an email to the licensee notifying them that the original shipment of P-32 has not been located and they were closing the case. On March 4, 2021, the Iowa Department of Public Health contacted the University of Iowa Radiation Safety Officer (RSO) and was informed by the RSO that the original shipment of P-32 is still missing. The activity of the P-32 as of March 4, 2021 is approximately 244 microcuries. Item Number: IA210001 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 55525 | 5 October 2021 05:00:00 | Agreement State | Agreement State - Lost I-125 Radioactive Seed | The following was received from the Iowa Department of Public Health (IDPH) via email: On October 5, 2021, the University of Iowa's radiation safety officer (RSO) contacted the Iowa Department of Public Health (IDPH) regarding a lost Iodine-125 (I-125) seed used for a localization of non-palpable lesion in breast tissue. The excised specimen containing two I-125 seeds had been received in pathology at 1704 CDT on 10/4/2021. The specimen was removed from container, surveyed with a Geiger counter, and imaged in the PathVision Faxitron by prosector. The radioactive seed localization (RSL) tracking sheet that came with the specimen from surgery indicated that two seeds were removed and two radioactive seeds were identified with associated biopsy clips via Faxitron imaging. The specimen was taken from the Faxitron to Grossing Workstation #3 and triaged by pathology staff. Triaging included weighing, measuring, and inking. Two cuts were made, one cut per biopsy site, in order to facilitate specimen fixation and to meet cold ischemia time requirement of one hour. A fixing tin was filled with formalin and the specimen was transferred to the fixing tin and appropriately labeled. Sharps waste were deposited in the sharps container at Grossing Workstation #3. Disposable materials used during triaging (absorbent pads, ink applicators, weigh boat, paper towels, gauze, and gloves) were deposited in the red biohazard waste at Grossing Workstation #3. Original specimen container and fixing tin were placed on the radioactive storage shelves by the Faxitron for overnight storage. Sometime between 1900 CDT 10/4/21 and 0700 CDT 10/5/21, housekeeping staff came in and collected trash and cleaned the floors. Laundry was collected between 0730 and 0800 CDT on 10/5/21. At 1100 CDT on 10/5/21, pathology staff brought the specimen to Grossing Workstation #5. They removed the specimen from the fixing tin, made multiple cuts into the specimen, laid out the slices on a Faxitron specimen tray, and attempted to image the specimen. The Faxitron malfunctioned and was not able to be brought to working order. Staff then laid out the specimen slices on the photo stand to take a photograph for a section diagram (instead of a Faxitron image for a section diagram). The photo was taken and the specimen was returned to Grossing Workstation #3. Photo stand was cleaned and waste from cleaning the photo stand was deposited in red biohazard trash at Grossing Workstation #5. A centrally located radioactive seed (seed #1) and associated biopsy clip were identified and removed from the specimen. Seed #1 was placed in a mesh bag and placed in a lead vial. The specimen at site of Seed #2 was then serially sectioned in an attempt to locate Seed #2 and its associated biopsy clip. The biopsy clip associated with seed #2 was found, but seed #2 was not found. The adjacent tissue was examined as well and without finding seed #2, the Geiger counter was then utilized to localize the second radioactive seed. The Geiger counter had no reading above background, indicating no seed present. Seed #1 was removed from the lead vial and scanned with the Geiger counter and had a reading of 5 mR/hr. Four lab staff immediately began looking for the radioactive seed, both visually and with the Geiger counter. They checked clothing and shoes of any staff who had been around the specimen. They checked the original specimen container as well as the fixing tin. Workstations #3 and #5 were thoroughly checked and re-checked, including trash cans, work surfaces, shelves, materials on shelves, drawers, sharps containers, sinks, floors, and associated carts. The walkway between workstations #3 and #5 and the Faxitron and photo stand were checked, as well as the floor and any trashcans along the way. Additionally, the Faxitron chamber table were checked as well as the associated shelf, floor and trash can. When Seed #2 could not be found by the lab staff, the pathology supervisor contacted the RSO as well as Nuclear Medicine to notify them of a missing radioactive seed. RSO called and discussed what occurred with the pathology supervisor and sent two members of the Radiation Safety section of University's Environmental Health & Safety, who surveyed the same areas as the lab staff had scanned, as well as the changing room and the area of the laundry hamper, but were unable to locate Seed #2. On October 6, the RSO surveyed all of the waste containers and bags that were in the (University of Iowa Health Care) (UIHC) biohazard waste storage room at UIHC. This consisted of three large containers and one very large container, containing dozens of biohazard waste bags in total. It could not be confirmed whether or not it was likely that the bag removed from surgical pathology between 1900 CDT on 10/4/21 and 0700 CDT on 10/5/21 would have still been in the waste storage area. The RSO did not note any readings above background on the survey meter used to do the survey, and given the potentially hazardous nature of the contents, did not pursue a closer examination of the biohazardous waste. Due to the large search and survey response from pathology, nuclear medicine, environmental health & safety, and RSO, it was determined that there is a high probability the seed was wrapped up in absorbent materials used in the triage process and placed into a biohazard waste bin and removed from the department overnight. Iowa Event Number: IA210004 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 |