ENS 51937
ENS Event | |
|---|---|
05:00 May 13, 2016 | |
| Title | Agreement State - Lost Brachytherapy Source |
| Event Description | The following was reported verbally and via email from the Illinois Bureau of Radiation Safety:
On Friday, May 13, 2016, the licensee's radiation safety officer (RSO) contacted the Agency [Illinois Bureau of Radiation Safety] to advise that one source from a Medi+Physics sealed source brachytherapy device [44 mCi, Cs-137, Model Number CDCT1, Serial Number GA301] was missing following the treatment of a patient. During the unloading of the applicator that afternoon, only 2 of the 3 sources were recovered. Surveys were immediately conducted of the patient, the patient's room, the trash, bed and linen that remained present as well as several potential paths to and from the hot lab where the sources are stored. The facility expanded its surveys to additionally include dumpsters, roll off containers of biohazard waste and soiled linen storage without retrieving the source. Interviews with attending nursing staff showed that the patient had been cooperative throughout the 3 day treatment, did not have any visitors and had no complications where she had been found out of bed or otherwise unattended. Agency representatives were sent to the facility the following Monday to conduct confirmatory measurements of the same areas and equipment and expanded the search again to other outlying areas of the facility with no unexpected elevated readings detected in any area. Waste processing facilities were contacted and advised of the potential of a missing radioactive source in their waste stream beginning on the previous Wednesday. All indicated that they had functioning portal detection units for incoming trash/waste and that no anomalous readings had been noted. The Agency is continuing its investigation at this time and conducting additional surveys at out lying waste facilities. Hospital staff have been made aware of the event and been given a description of the source and appropriate action to take should it be discovered. This item remains open at this time. 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 |
| Where | |
|---|---|
| John Stroger Hospital Chicago, Illinois (NRC Region 3) | |
| License number: | IL-01768-01 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+102.9 h4.288 days <br />0.612 weeks <br />0.141 months <br />) | |
| Opened: | Daren Perrero 11:54 May 17, 2016 |
| NRC Officer: | Karl Diederich |
| Last Updated: | May 17, 2016 |
| 51937 - NRC Website | |
John Stroger Hospital with Agreement State | |
WEEKMONTHYEARENS 519372016-05-13T05:00:00013 May 2016 05:00:00
[Table view]Agreement State Agreement State - Lost Brachytherapy Source 2016-05-13T05:00:00 | |