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| Entered date | Event description | |
|---|---|---|
| ENS 50692 | 18 December 2014 12:57:00 | On 16 December 2014, at 1800 (PST), a patient was prescribed to receive 8-12 mCi of I-123 MIBG (metaiodobenzylguanidine). The dose was delivered late to the Nuclear Medicine clinic and fell below the prescribed dosage range. The Nuclear Medicine OIC (Officer-in-Charge) changed the prescribed dosage from 8-12 mCi to 7-12 mCi, and the patient was subsequently dosed with 7.81 mCi. The procedure was successful and did not result in any medical/health impact or further need to repeat the study. (The Nuclear Medicine OIC) is currently not an authorized user (AU) on USAF Radioactive Material Permit No. CA-07840-03/07 AFP; therefore, he does not have the authority to adjust the prescribed dosage range. It is worth noting that (the Nuclear Medicine OIC) meets all the requirements to be an AU, and a request to add him was included with our pending permit renewal application provided to the Radioisotope Committee Secretariat (RICS) (USAF Licensee). Location: Travis AFB, David Grant USAF Medical Center 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 49766 | 27 January 2014 08:39:00 | The following report was received via email; 1. IAW 10 CFR 20.2201(a)(1)(ii), we are providing a written report for the loss of radioactive material. The loss of material was reported on 27 Jan 14; 1) telephonically to NRC Operations Center, Event No. 49766 and 2) via E-mail to NRC, Region IV (Ms. Cook). The following information addresses the reporting requirements: a. Description of the licensed material: The subject device contained nickel 63 (Ni-63), one source, at 15 millicuries. The source is encapsulated in a hollow brass cylinder which in turn is sealed in a ceramic shield as referenced in Sealed Source & Device Registry (SS&DR) NR-0163-D-102-E (19 Oct 2010). The subject device was generally licensed (GLD) and used by USAF Security Forces Personnel (75th SFS) of Hill AFB, Ogden, UT. b. Description of circumstances for loss: The missing Ionscan 500DT was added to the Installation Radiation Safety Officers inventory of all GLDs on Hill AFB in October 2007. The serial number of the missing source is 50083. It was surveyed semi-annually through May 2013. During the November 2013 leak test/inventory of GLDs, the device was not at the security gate where it has always been. The 75 SFS storage warehouse was checked and it was not there either. c. Statement of disposition: 75 SFS personnel were asked multiple times about the disposition of the item. On 11 December 2013, they reported the Ionscan was no longer in their possession. They reported that the item was dropped and damaged during transport. An Airman was assigned to locate a disposal location that would be able to take the item and was directed to dispose of it there. Later the Airman reported that he had done this. The Airman was in the process of being dismissed from the Air Force at that time and is no longer in the Air Force for questioning on how he disposed of the item. Therefore, the final disposition of the item is unknown at this time. d. Exposures to individuals: Because the device contains Ni-63, which is sealed and incorporated into the Ion Mobility Spectrometer assembly, the radiation level surrounding the device would be indistinguishable from background. e. Actions taken: Requests have been made of multiple levels of 75 SFS command to obtain more specifics on the event. No additional information has been received to-date. f. Procedures/measures to rectify future loss: The installation radiation safety officer will reinforce the policies outlined in Air Force Instruction (AFI) 40-201, Managing Radioactive Materials in the United States Air Force for proper disposal of generally licensed devices. 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 |