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| Entered date | Event description | |
|---|---|---|
| ENS 55929 | 7 June 2022 08:28:00 | The following was received from the Pennsylvania Department (DEP) Bureau of Radiation Protection via email: On June 5, 2022, the DEP was present for the removal of an irradiator at Children's Hospital of Philadelphia, a location on University of Pennsylvania license (PA-0131). A crew member of the rigging subcontractor was seen livestreaming the operation. Campus police were immediately notified, the filming was stopped, and the crew member was removed from the site. The DEP is investigating and will update this event as soon as more information is provided. Event Report Identification Number: PA220020 |
| ENS 55998 | 18 July 2022 06:58:00 | The following information was provided by the Pennsylvania Bureau of Radiation Protection via email: On July 15, 2022, the licensee discovered a lost Americium-241 source. The 100 millicurie source is in a FILTEC model FT-50 gauge (Serial Number 116888). During an inventory for its license renewal, the licensee discovered the device missing from its location in storage and has been unable to locate the device. The licensee has notified its facilities and engineering departments, plans on contacting the manufacturer on July 18th to see if the gauge was returned, and is actively searching for the source. The DEP (Department of Environmental Protection) was in contact with the licensee over the weekend for information and will update this event as soon as more information is provided. Pennsylvania event number: PA220023 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 56273 | 15 December 2022 09:46:00 | The following information was provided by the Pennsylvania Bureau of Radiation Protection (the Department) via email: On December 14, 2022, a consultant health physicist informed the Department that a Troxler Model 104-117 nuclear density gauge, serial number 433, containing 3 millicuries of radium-226 beryllium (Ra:Be) had been found. The gauge was found in a trash transfer trailer entering Waste Management, Mountain View Reclamation Landfill on December 2, 2202. This load originated from West Virginia. The load was isolated until consultant health physicist was able to respond on December 13, 2022, to resurvey the trailer. A gamma radiation measurement made at contact with the source housing was 18 milliroentgens/hour. At 1 foot from the approximate location of the source, the gamma dose rate was 5 mrem/hour. No evaluation was made of the neutron dose rate. The device was placed in a locked storage shed posted with a Caution - Radioactive Material sign. The Department was onsite during the recovery of the gauge and continues to investigate its origin. The Department will update this event as soon as more information is provided. Event Report ID No.: PA220030 |
| ENS 56319 | 20 January 2023 15:46:00 | The following information was provided by the Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (the Department) via email: On January 20, 2023 the licensee informed the Department of an under-dose incident involving yttrium-90 (Y-90) TheraSpheres. It is reportable per 10 CFR 35.3045(a)(1). On January 11, 2023 an Authorized User (AU) in Interventional Radiology was attempting to treat a patient with 45.4 mCi of yttrium-90 TheraSphere. The AU could not get the spheres to infuse. After consultation with the manufacturer (Boston Scientific), they decided on aborting the procedure. It was determined the patient received zero activity and all the radioactivity from the spheres remained inside the treatment vial. The patient and referring physician have been informed. The Department is currently in contact with the licensee and will update this event as soon as more information is provided. Event Report ID No: PA230005 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 56425 | 22 March 2023 14:17:00 | The following information was received from the Pennsylvania Department of Environmental Protection via email: On March 21, 2023, the licensee discovered a broken shutter on one of its devices, a Berthold, LB8010, Serial number 10094, with 20 mCi of cesium 137. The licensee reported the shutter is in the closed position and cannot be moved. The device has been removed from service and secured at the licensee's storage facility in Mill Hall, PA. The manufacturer has been contacted. The gauge will be returned for repair or replacement. No personnel overexposure has occurred. PA Event Report Id NO: PA230012 |
| ENS 56488 | 26 April 2023 08:37:00 | The following information was provided by the Pennsylvania Department of Environmental Protection (the Department) via email: On April 25, 2023, the licensee reported damage to a QSA 880D (number D7890, source serial number 72481M), camera containing 105.8 Ci of Ir-192. While using the device shooting a 3-inch pipe positioned on a cart, the pipe fell off the cart and landed on the guide tube. The guide tube was damaged and left the source capsule in the exposed position unable to retract or to be placed back in the collimator. Lead blankets were placed on the damaged area of the guide tube. Dose rate at the established boundary was confirmed to be 0 mR/hr. The licensee staff calculated doses received to the 4 employees involved in the retrieval as 98, 310, 570, and 750 millirem. Badges have been sent to Landauer for emergency processing. The source was able to be secured safely in the device, locked in the licensee's vault, and tagged out of service. The device will be sent to the manufacturer to be inspected. The Department will perform a reactive inspection. More information will be provided upon receipt. PA NMED Event Number: PA230014 |
| ENS 56526 | 19 May 2023 12:03:00 | The following information was received from the Pennsylvania Department of Radiation Protection via email: On March 28, 2023, a patient was treated with a permanent Cs-131 implant with a prescribed dose of 60 Gy. On April 11, 2023, the patient presented with a serious medical condition which necessitated the immediate removal of the implant. The seeds were all accounted for and placed into storage for decay to background. The actual dose delivered is calculated to be 37 Gy. The referring physician and the patient have been informed. Event Report Identification Number: PA230015 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 56536 | 24 May 2023 08:37:00 | The following information was provided by the Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (the Department) via email: On May 24, 2023, the Department was notified of a stolen nuclear density gauge. This event is reportable within 24-hours per 10 CFR 20.2201(a)(1)(i). On May 23, 2023, an employee of the licensee reported to police that their vehicle, with a nuclear density gauge in it, was stolen earlier that day. Local, Regional, and State Police are aware of the incident and a bulletin has been issued. (The Department) has been in contact with the licensee and will update this event as soon as more information is provided. The Department will perform a reactive inspection. Stolen gauge details: Troxler Model Number: 3440 Serial Number: 33833 Sources: Cesium 137, 9 millicuries; Americium 241:Be, 44 millicuries
The following information was provided by the Department via email: The vehicle has been recovered with the device still secure and intact in the trunk. Notified R1DO (Jackson), NMSS Events Notification (email), ILTAB (email), CNSC Canada (email). PA Event Report Number: PA230016 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 56689 | 22 August 2023 13:37:00 | The following information was received via email from the Pennsylvania Department of Environmental Protection (the Department): On August 21, 2023 the licensee informed the Department of a medical event where the equipment failed to function as designed. This is reportable under 10 CFR 30.50(b)(2). A patient was scheduled for an intravascular brachytherapy (IVBT) patient treatment using a Beta-Cath Strontium 90 device (s/n 91273) and upon source retraction the source failed to return to the transfer device due to a kink in the catheter. An emergency 'bailout' procedure was performed, with the cardiologist removing the delivery catheter and guidewire from the patient. The delivery catheter was left attached to the transfer device and placed it into the temporary plexiglas 'bailout' box. The patient was surveyed to confirm the source had been removed. The 'bailout' box was visually inspected and surveyed to confirm the source was in the catheter in the box. This box was then transferred to the radiation oncology secure storage area. The device will be returned to the manufacturer for inspection. No overexposures were reported. The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received. PA Event Report ID Number: PA230022 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.
The following information was received via email from the Department. The event type has been changed from a medical event to a Part 30 equipment event. The Department has learned that the authorized user said that treatment was complete and the source did not enter the device within 3 seconds so they started emergency removal of catheter from the patient and placed it in the 'bailout' box; total time from end of treatment to the catheter/device in the emergency box was approximately 10 seconds. The kink in the catheter was noted after it and the source were approximately 15 cm from where it entered the patient thus no overexposure or unintended dose. Device make, model, serial number: Best Vascular, Inc, A1000 Series Models, Transfer Device s/n 91273. Radionuclide: Sr-90; Jacketed Radiation Source Train s/n ZB948 (60 mm source train) (24 sources). Source strength(s): 3.13 Gbq (84.6 mCi) total; (3.52 mCi/source * 24 sources); Assay date 12/3/2003; Activity as of August 21, 2023 = 1.92 Gbq (51.9 mCi) total. Dose patient received:18.4 Gray @ 2 mm; (vessel 3.0 mm). Dose patient prescribed:18.4 Gray @ 2mm (vessel 3.0 mm). Notified R1DO (Gray) and NMSS Events Notification email group. |
| ENS 56695 | 24 August 2023 13:03:00 | The following information was received via email from the Pennsylvania Department of Environmental Protection (the Department): On August 24, 2023, the licensee informed the Department of an under-dose incident involving cesium-131 (Cs-131). It is reportable per 10 CFR 35.3045(a)(1). On August 23, 2023 a patient received prostate seed therapy with Cs-131. The therapy plan detailed the need for 24 needles with 98 Cs-131 seeds total (1.8U/seed). A total of 107 Cs-131 seeds were received by the facility, based on the pre-plan volume. Devices used in the operation included: Ultrasound - BK Medical, BK 3000, serial number: 2003107; Planning System - Varian, Variseed 9.0, serial number: B29WL33; Stepper and applicator - CIVCO, Classic Stepper, serial number: 02107; MICK Medical, Mick TP applicator. Seed assay was performed with the activity per seed within acceptable regulatory limits. However, after the medical procedure, more than 37 seeds were found unused. According to the plan, the unused number was supposed to be 9. Thus, a total of 70 seeds were implanted. The physician and patient have been informed. The patient received 201.9 mCi (70 seeds) of the 282.6 mCi (98 seeds) prescribed. The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received. Pennsylvania Event Report ID No.: PA230023. 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 56725 | 7 September 2023 12:40:00 | The following summary information was provided by the PA Bureau of Radiation Protection (PA DEP) via email On September 6, 2023 a Troxler gauge, model 3411, serial number 6829 was hit by a vehicle while on a job site. This gauge contained a 9 millicurie Cesium-137 source and a 44 millicurie Americium 241:Be source. The area was secured, and the PA DEP responded to the site. The owner/radiation safety officer (RSO) retrieved the sources with long handled pliers and secured them in the transportation box for the gauge. The area and gauge were surveyed and smears were taken for contamination. The case was also surveyed and the owner/RSO has contacted a consultant/vendor to leak test the sources and arrange for disposal. Pennsylvania Event Number: PA230024 |
| ENS 56770 | 2 October 2023 10:19:00 | The following information was provided by the Pennsylvania Bureau of Radiation Protection via email: On September 28, 2023, staff from Magee Pathology department called the (University of Pittsburgh) radiation safety office to report that they had accidentally transected an I-125 seed used for radioactive seed localization (RSL) in breast tissue during the pathology processing in the laboratory. The seed was a Best Medical International Model 2301 containing 169 microcuries of I-125. Two staff members were involved, and they were told to sequester in the room until personnel from radiation safety could respond. Shortly after, radiation safety personnel performed surveys to determine the extent of the contamination. No personnel contamination was observed. All contamination was discovered in waste material and on the tissue samples. The transected seed was contained. The radiation safety office took possession of the damaged seed and all radioactive waste. At the time of reporting, it is estimated that approximately 50 percent of the activity was lost to open contamination, which is greater than 1 annual limit on intake (ALI) of I-125, and therefore reached the criteria for (10 CFR) 22.2202 reportability. Workers had bioassays performed for thyroid exposure and all returned negative. PA event report ID: PA230028 |
| ENS 56962 | 13 February 2024 08:14:00 | The following information was provided by the Pennsylvania Bureau of Radiation Protection (DEP) via email: On January 18, 2024, the licensee's radiation safety officer (RSO) was completing shutter checks and leak tests on a Berthold fixed gauge, model number: LB-300 W, serial number 1744-11-14 containing sealed source number P-2608-100 with 8 millicuries of Co-60. During the checks, the shutter's shear pin broke, and the RSO was unable to close the shutter. The vessel that this gauge is on is not entered very often and is not readily accessible. A licensed contractor will be on site on February 13 - 14, 2024, to repair the gauge. If they are not able to repair the gauge on-site, the gauge will be placed in storage until it can be sent for repair. The DEP has been in contact with the licensee. PA event report ID: PA240004 |
| ENS 56972 | 16 February 2024 14:29:00 | The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) email: On February 1, 2024, a patient was receiving a lutetium-177 (Lutathera) treatment. The written directive, signed by the authorized user (AU), was for 200 mCi of Lu-177. However, the treating medical oncologist signed a 100 mCi dose alteration treatment plan order on the same day as the procedure. The patient received the 200 mCi dose that was recorded in the written directive instead of what was intended. It is believed that miscommunication occurred between the two, and a full investigation into the cause of the event is underway by the licensee. The AU and the patient have been notified. No harmful effects are expected to patient. The Department will update this event as soon as more information is provided. PA NMED Event Number: PA240005 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 57081 | 18 April 2024 16:32:00 | The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) email: On April 18, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045. On April 17, 2024, a patient was receiving an iodine-131 (sodium iodine solution) treatment. The patient was prescribed 100 mCi of I-131. However, the patient received only 5 mCi of I-131. At this time no other information is available. The Department will update this event as soon as more information is provided. The Department will perform a reactive inspection. More information will be provided upon receipt. PA Event Number: PA240006 A Medical Event may indicate potential problems in a medical facilitys use of radioactive materials. It does not necessarily result in harm to the patient. |
| ENS 57084 | 22 April 2024 13:44:00 | The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email: On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045. On April 19, 2024, the licensee discovered a medical event from December 28, 2022. A patient received a diagnostic scan that was performed using 1 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensees system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient. At this time, no other information is available. The Department will update this event as soon as more information is provided.
The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email: The Department wishes to retract this event as it does not meet the qualifications for reporting. Notified R1DO (Werkheiser) and NMSS Events Notification via email. PA Event Number: PA240008 A Medical Event may indicate potential problems in a medical facilitys use of radioactive materials. It does not necessarily result in harm to the patient. |
| ENS 57085 | 22 April 2024 13:44:00 | The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email: On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045. On April 19, 2024, the licensee discovered a medical event from December 29, 2022. A patient received a diagnostic scan that was performed using 1 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensees system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient. At this time, no other information is available. The Department will update this event as soon as more information is provided.
The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email: The Department wishes to retract this event as it does not meet the qualifications for reporting. Notified R1DO (Werkheiser) and NMSS Events Notification via email. PA Event Number: PA240009 A Medical Event may indicate potential problems in a medical facilitys use of radioactive materials. It does not necessarily result in harm to the patient. |
| ENS 57086 | 22 April 2024 13:44:00 | The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email: On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045. On April 19, 2024, the licensee discovered a medical event from January 31, 2023. A patient received a diagnostic scan that was performed using 4 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensees system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient. At this time, no other information is available. The Department will update this event as soon as more information is provided.
The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email: The Department wishes to retract this event as it does not meet the qualifications for reporting. Notified R1DO (Werkheiser) and NMSS Events Notification via email. PA Event Number: PA240010 A Medical Event may indicate potential problems in a medical facilitys use of radioactive materials. It does not necessarily result in harm to the patient. |