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| Entered date | Event description | |
|---|---|---|
| ENS 51090 | 26 May 2015 16:04:00 | The following report was received from the Illinois Emergency Management Agency via email: On the afternoon of May 21, the Agency (Illinois Emergency Management Agency) received a call from the licensee's radiation safety officer (RSO) who explained that their portable moisture density gauge had been involved in an accident at a construction site in Barrington, IL. The gauge operator had been briefly called away from the device and during his absence, the device was struck by a piece of heavy machinery. The RSO indicated that the operator had gathered up the pieces and put them into the transportation case and was in the process of returning the broken device to the company's Chicago storage facility at the time of the RSO's notification. Pictures provided by the RSO showed that the rod which contained the Cs-137 was significantly bent some 4 inches from its end and was no longer in its shielded position. The operator secured the device in a remote location upon his return to the storage facility that night until Agency inspectors could be dispatched to the location. The next morning, inspectors arrived at the storage location and conducted surveys including field leak tests of the sources. Those tests showed no leakage of radioactive material but determined that elevated radiation levels of up to 60 (millirem/h) were present at the surface of the transportation case. After providing additional storage suggestions, the pieces of the gauge were reconfigured and secured at the site. Dose rates were lowered to 16 (millirem/h) near the surface of the case and less than 1 (millirem/h) at 1 foot by those efforts. The gauge manufacturer was contacted and asked to provide a shipping container and additional shielding for return of the damaged device. When those materials are received, Agency inspectors will return to the site and verify the gauge is properly packaged and documented for return. This item remains open at this time pending this additional action and receipt of the licensee's written report which is due in 30 days. Device manufacturer: Troxler Model Number: 3430 Serial Number: 68332 Device activity content: 0.008 Ci - Cs-137, 0.040 Ci - Am/Be Illinois Event Number: IL15011 |
| ENS 50268 | 10 July 2014 15:33:00 | The following information was received via fax: On July 9, the licensee's radiation safety officer called to report a potential medical event had occurred the previous afternoon. The Agency was advised that an interstitial treatment could not be completed involving a High Dose Rate afterloader (HDR) at the University of Illinois at Chicago. As a result of safety features built into the HDR's programming, the first fraction of a four fraction treatment of 300 rad was automatically terminated and the source returned to the safe/stored position after only 6 rad had been delivered when unexpected resistance was detected in the source wire as it moved to the second dwell position. Subsequent attempts to clear the path and reinitiate the treatment were unsuccessful. As a result, an underdose of 98% of the fraction occurred. The HDR unit was subsequently re-run through its quality assurance tests for positioning accuracy with no anomalies noted. The patient was notified of the event immediately. A week before, the patient had 3 catheters surgically placed near the pelvis and their location relative to the treatment site verified by CT scan with an additional scan just before treatment was initiated. After reviewing the scan the written directive was modified to call for 18 dwell positions in three channels for a duration of 101 seconds. Four fractions were going to be completed on successive days. The scan suggested the possibility of the catheters being moved as a result of distention of some internal organs. Although the 'dummy' wire successfully traversed the initial path, and the active wire reached the first treatment position, after the initial 2 seconds of programmed dwell time, the HDR unit detected an unexpected delay in the wire moving to the second dwell position, presumably due to constriction of the pathway, and automatically retracted the active wire to the safe store position. With the assistance of the manufacturer's off site technical advisor, the error code was cleared and attempts were made to reinitiate the treatment however, the 'dummy' wire could not traverse the path and the treatment abandoned. In this instance the device performed as designed and subsequent quality assurance tests confirmed the device was operating as expected. Although no effect on the patient is expected from the event, physicians are determining what course of treatment options are available at this time. The licensee was advised of the requirement to submit a written report of the event in accordance with the regulations. Pending additional developments and submission of the report, this matter remains open for now. The HDR Afterloader has a 5 Ci Ir-192 source and was being used to treat a cancer in the pelvic area. Illinois Report Number: IL14011 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 49484 | 30 October 2013 14:36:00 | The following report was received from the Illinois Emergency Management Agency via e-mail: On October 29, 2013, the RSO at Loyola University Medical Center (IL-01131-02) called to report a medical event which occurred at their facility the previous day. A treatment dose of 115 Gray (10.5 mCi) of Nordion's Y-90 Theraspheres was prescribed. However, at the completion of the treatment and in accordance with manufacturer's use instructions, the system was evaluated for residual material. Elevated levels were detected within the combination of the catheter, tubing and source delivery vial apparatus. Those elevated levels were determined to correspond to over 2 mCi of Y-90. A detailed evaluation revealed 8.04 mCi had been administered for a total delivered dose of 88 Gray or 76.5% of the intended dose. Most of the remaining 2.5 mCi of Y-90 was adhered within the catheter about 1 inch from the catheter/tubing interface connector despite successfully completing the treatment in less than a minute including 3 successful flushes of the system with 30 cc of sterile solution. No material was detected as remaining in the source vial which was monitored closely during the treatment with a dedicated dosimeter nor were there any observable defects in the catheter or manufacturer supplied tubing where the microspheres had accumulated. As per regulations, the patient was advised of the situation by the interventional radiologist. Neither the physician authorized user, an oncologist, nor the interventional radiologist believes that there will be any adverse impact to the patient as a result of the lowered dosage. There are no plans to supplement/repeat this treatment to deliver any remaining/additional amount of radiation nor does the licensee have any immediate corrective actions to implement in that the procedure already follows the manufacturer's recommendations. The licensee is aware of the requirement to submit a written report within 15 days. The cause of this event was equipment failure. Illinois Item Number: IL13032 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 47062 | 15 July 2011 15:22:00 | The following report was received from the Radioactive Materials Section of the Illinois Emergency Management Agency: (Arcos Environmental) a General Licensee, called the agency (Illinois Emergency Management Agency (IEMA)) to advise that a x-ray fluorescence analyzer (containing a 5 millicurie Cd-109 source) for measuring lead content of paint was stolen from a locked vehicle while at a temporary jobsite. The device along with several other items was removed from the car's trunk while it was parked at 6020 S. Langley Ave., Chicago, IL. At the time of the theft, the responsible user was in a building performing other duties. The theft was promptly reported to the Chicago Police Department. The general licensee is considering a news paper ad to encourage return of the device to its Tinley Park offices. Use of the device requires a 'pass code' to activate the device's features and allow exposure of the radioactive source by the opening of an internal shutter. The pass code is maintained separate from the device. In addition, 6 years after the source has been installed, the device will no longer operate and a display message directs that the device be returned to the manufacturer. This device was initially sourced in Sept of 2007. The maximum surface dose rate from the device is less than 100 microR/h when the shutter is closed. Based on the SSDR safety evaluation the maximum exposure rate, should the safety and security features be defeated and the shutter opened, would be 3 milliR/h. As a result, the potential radiation exposure to the thief or any member of the public is projected to be extremely low. The general licensee has been advised of the requirement to file a written report within 30 days of the theft. The agency (IEMA) does not intend to conduct an on-site investigation unless additional information or circumstances change which warrant a visit. Illinois Report Number: IL11086 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 41521 | 24 March 2005 11:48:00 | GE Healthcare, also known as Medi Physics, reported that a package of radioactive material had not been received as expected by Northwest Arkansas Medical Center in Springdale, Arkansas. The package, which contains 105 brachytherapy seeds, was to be delivered on Monday March 21, 2005. The seeds contain approximately 0.63 milliCi of activity each, with a total package activity of 66 milliCi. The maximum radiation level on the surface of the package is less than 0.5 milliR/hr. The material was sent via FedEx on Friday March 18 and received at the FedEx facility in Tulsa, Oklahoma on March 19. No further information has been logged since. Medi Physics' customer service group has begun their investigation. The Arkansas Division of Radiation Control has been advised of the situation. IL report number: IL050022
The State of IL, Division of Nuclear Safety, called to indicate the missing package containing 105 brachytherapy seeds was located in the Fed Express facility in Arkansas. The package, which was estimated to be found about 11:30 EST on 3/25/05, was intact and in its original condition. The licensee believes the missing package was in the possession of Fed Ex at all times, with no third party intervention. The brachytherapy seeds are being returned to G.E. Healthcare to determine that all seeds are accounted for and to further investigate how the package was lost within the Fed Ex system. Notifications were given to R3 (Kozak), NMSS (Moore), and TAS (Sandler). |