Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 55850 | 20 April 2022 09:36:00 | The following is a synopsis of an email received from the state of Georgia: On April 14, 2022, the state of Georgia received the following complaint from the licensee's Assistant Radiation Safety Officer (ARSO): the licensee had a shipment of Y-90 seeds that was supposed to be delivered from Sirtex on the morning of April 11, 2022 for a procedure. The package did not arrive. The ARSO was notified on April 12, 2022 and reported the information to the state of Georgia on April 13, 2022. The package contained 81 milliCi of Y-90 spheres. The ARSO was unable to obtain any information about the location of the shipment from the common carrier. Georgia Incident Number: 53
The following is update was received from the state of Georgia via email: On April 25, 2022, Georgia received notice that the package had been located and is being returned to Sirtex. Georgia has closed the incident. Notified R1DO (Young) and ILTAB and NMSS Events Notification via email. 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 55381 | 28 July 2021 11:19:00 | The following was received via email from the Georgia Radioactive Materials Program: A gauge was reported hit by a bulldozer (while on site) on 7/27/21. The rod was not exposed and there is no contamination leaking. Incident #: 43 |
| ENS 54879 | 3 September 2020 17:27:00 | The following is a synopsis of the event received from the Georgia Radioactive Materials Program: On July 31, 2020, a physician did not follow proper procedure while recording the number of seeds administered to a patient. The physician initially planned on administering one seed but decided to administer two. The physician did remove both seeds from the patient on August 3, 2020. The tracking system for the administered seeds was based on writing the number of seeds administered on a colored bracelet or arm band, which the patient wears while the seed(s) are implanted. It is removed and travels with the removed tissue through the remaining processes at the hospital. In this case, the physician did not revise the number on the bracelet, therefore during the subsequent processes, other hospital staff only looked for one seed to recover from the procedure by-products. One seed was not recovered. There was some discussion between departments prior to August 21, 2020 about the seed. Radiation Safety was not contacted. On August 21, 2020, an Assistant RSO discovered the discrepancy while conducting an inventory, preparing the seeds for return to the seed vendor. Subsequent searches that included the involved staff did not recover the missing seed. After a review of the laboratory processes for analyzing the removed tissue, the hospital staff believes the missing seed was retained in the transport bin and disposed of with that bin in the bio-hazard waste stream. But, this can not be proven. It was demonstrated to not be in the frozen sample that the hospital retained. The hospital declared the seed lost on August 27, 2020. The seeds were I-125 encapsulated in titanium. Model IAI-125A. Activity level calculated to be 145.1 microCuries at time of loss/disposal. The radioactivity is small, and the decay rate high such that this poses a low risk to the public. Based on literature, the RSO states the contact dose, assuming the seed was trapped in clothing (contact) for twelve hours to be 2.66 milliSeverts. The hospital has conducted a root cause analysis, and has revised its procedures and re-trained staff to prelude future loss of radioactive seeds. Incident #: 29 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 53774 | 4 December 2018 16:06:00 | The following information was received from the State of Georgia via email: In accordance with Georgia Rule Chapter 391-3-17-.03-15(b)(3)(ii) (the licensee is notifying the Georgia Radioactive Material Program) of a potential extremity exposure exceeding regulatory limits to an occupational worker at Northside Hospital Atlanta. The timeline and circumstances are as follows: Northside Hospital received notification from Landauer ((the licensee's) personnel dosimetry vendor) on November 2, 2018, concerning an excessive reading of 58,748 millirem to an extremity dosimeter issued to (an employee) in Nuclear Medicine. (The licensee's) RSO immediately initiated an investigation which included a personal interview with the employee which resulted in the employee remembering the potential contamination of their ring dosimeter with a radiopharmaceutical as they were handling and injecting a patient dose during the period of use for that dosimeter; however, he was unsure as to the actual presence of contamination on the ring itself. The RSO assured the employee of the lack of any untoward effects but asked him for a follow-up for any skin effects that may have presented. Also it was noted that the whole body dosimeter during the same period showed only 25-30 millirem exposure. Based on this incident, there will be a renewed emphasis for all Nuclear Medicine Technologists that in the event of potential contamination to themselves and particularly to any personnel dosimeter, an immediate investigation by (the licensee's) RSO will be initiated and a report filed with (the licensee's) Radiation Safety Committee. |