Semantic search
Jump to navigation
Jump to search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 54510 | 29 January 2020 05:00:00 | Agreement State | Agreement State Report - Incorrect Organ Received Treatment | The following was received from the South Carolina Department of Health and Environmental Control via email: The South Carolina Department of Health and Environmental Control was notified on 02/03/2020 of a potential medical event involving a prostate seed implant. The procedure occurred on 01/29/2020, and the licensee's radiation safety officer was notified of the potential medical event on 02/03/2020. The prescribed dose to the prostate was 145 Gray, with 76 seeds being implanted. Total activity of the seeds is being reported as 26.6 milliCuries. The licensee is reporting that the seeds were implanted into the bladder and not the prostate. As of 01/31/2020, 41 seeds of the implanted 76 seeds were still implanted in the patient. The licensee is also reporting the loss of 35 seeds. The prostate seed manufacturer is ISOAID, LLC ADVANTAGE I-125. The model of the seeds is IAI-125A. This event is still under investigation by the licensee and the South Carolina Department of Health and Environmental Control. 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. Notified R1DO (Henrion) and NMSS Events (email) | ||
| ENS 54581 | 11 March 2020 12:15:00 | Agreement State | Agreement State Report - Stolen Gauge | The following information was received from the state of South Carolina via email: On March 11, 2020, the Department (South Carolina Department of Health and Environmental Control (SCDHEC)) was notified by the licensee at approximately 0815 (EDT) that a portable gauging device had been stolen from the licensee's storage location at 19 Highway 90 East, Little River. The gauging device is an Instrotek Model 3500 (moisture density gauge), serial number 722. This device contains 10 milliCuries of Cs-137 and 40 milliCuries of Am-241:Be. The licensee stated that the theft has been reported to local law enforcement. SCDHEC has notified the South Carolina Law Enforcement Division's Fusion Center. 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 54779 | 15 July 2020 13:45:00 | Agreement State | Agreement State Report - Stolen Moisture Density Gauges | The following is a summary from the South Carolina Department of Public Health received via phone: At 0945 EDT on 07/15/2020, the licensee's Radiation Safety Officer (RSO) notified the State that two Troxler moisture density gauges (model 3430P, serial #'s 72756 and 75041), each containing 8 mCi of Cs-137 and 40 mCi of Am-241, were stolen from their Ballentine, SC storage facility. The devices had not been used in a few days, so it is unknown when they were stolen. The RSO reports that the job box containing the travel cases were taken, but the locks were not cut. Additionally, the roll up gate was closed but not secured. The RSO believes it could be an inside job. The RSO was in the process of calling the police. 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 54830 | 10 August 2020 21:30:00 | Agreement State | Agreement State Report - Radiography Camera Drive Cable Failure | This was received from the South Carolina Department of Health and Environmental Control via email: On August 11, 2020, at 1500 (EDT), the Department (SC Department of Health and Environmental Control) was notified by the licensee that a drive cable used to crank out a source on a Spec 150 camera failed to function as designed. The radiographer was performing the initial source crank out of the source to check the 2 mR in any one hour boundary when he realized that the drive cable was not functioning properly and quickly retracted the source to the shielded position. The radiographer then contacted the Radiation Safety Officer (RSO) to provide him with the details. The RSO then cancelled the job for the night until the drive cable could be replaced. The RSO stated that there were no overexposures that occurred as a result of this incident. The RSO was informed by the Department's on-call duty officer that a 30-day written report will be required detailing the incident. The event occurred on Shaw Air Force Base. South Carolina Incident No: 54830 |