ENS 57877
ENS Event | |
|---|---|
07:00 Jul 8, 2025 | |
| Title | Lost Treatment Vial |
| Event Description | The following information was provided by the Nevada Division of Public and Behavioral Health via phone and email:
On July 8th, a Xofigo package [containing liquid Ra-223 dichloride solution of an unknown total activity] was checked in, and subsequent procedures were carried out for dose verification and disposal. However, the dose was later found to be missing, prompting an investigation. Upon receipt, the surface radiation level of the package was measured at 1.8 mR/hr. Wipe tests performed on both the inside and outside of the package registered 122 dpm. [There is no contamination concern at this time.] The dose was then checked into inventory as per protocol. The radioactive warning symbols on the package were defaced and physically removed. The package box was placed around the corner for the cleaning staff to dispose of. The following day, when attempting to retrieve the dose from the storage cabinet, it was discovered that the dose was missing. It was realized that during the initial wipe test, the dose had not been removed from the box before disposal. Efforts to locate the missing dose included checking outside trash bins, but these had already been emptied that morning. [The licensee] contacted maintenance personnel who liaised with the cleaning company and waste management services. Waste management confirmed that there is no method available to locate the missing dose and that it is likely disposed of in the main trash area. The Xofigo packaging weighs nearly the same whether it contains the dose or not, due to the plastic pig inside. To prevent recurrence, a new process has been implemented: the Styrofoam lid will be removed and discarded immediately after wiping to confirm the box is empty. Additionally, the entire box will now be discarded only after the dose has been administered to the patient. [The typical full manufactured container amount is 6.6 MBq/vial] 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 | |
|---|---|
| Urology Nevada Care Center Reno, Nevada (NRC Region 4) | |
| License number: | 16-12-14108-01 |
| Organization: | Nv Div Of Rad Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1018.92 h42.455 days <br />6.065 weeks <br />1.396 months <br />) | |
| Opened: | Corey Creveling 17:55 Aug 19, 2025 |
| NRC Officer: | Sam Colvard |
| Last Updated: | Aug 19, 2025 |
| 57877 - NRC Website | |
Urology Nevada Care Center with Agreement State | |
WEEKMONTHYEARENS 578772025-07-08T07:00:0008 July 2025 07:00:00
[Table view]Agreement State Lost Treatment Vial 2025-07-08T07:00:00 | |