Event Notification Report for April 21, 2006

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The State provided the following information via email:

"On April 21, 2006, the Radioactive Materials Program of Arkansas Department of Health and Human Services was notified by Central Arkansas Radiation Therapy Institute, ARK-654-BP-12-08, located in Little Rock, of a possible misadministration (medical event), which had been identified during the post-implant CT of a prostate implant patient. Based upon the CT scan, the facility determined that the I-125 seeds had been implanted in the incorrect area. The post-implant treatment plan generated on April 24, 2006, indicated that a dose greater than 50 Rem had been delivered to an unintended area of tissue.

"The licensee and Department will continue to investigate this event. A final written report regarding this misadministration (medical event) will be submitted within 15 days.

"NRC Region IV was notified of the potential misadministration on April 21, 2006."

* * * UPDATE RECEIVED FROM THE STATE (KIM C. WIEBECK) VIA E-MAIL TO JOE O'HARA ON 5/10/06 AT 0938 * * *

"As previously reported, on April 21, 2006 CARTI notified Arkansas Department of Health and Human Services of a misadministration (medical event) that occurred during an I-125 prostate seed implant. The final written report was received on May 9, 2006.

"The post-implant dosimetry imaging determined that the 84, I-125 seeds with average activity of 0.219 mCi on March 28, 2006, were misplaced approximately 4 cm inferior to their intended position. The post-implant dose calculation determined that a dose of 108 Gy, which was consistent with the prescribed dose, had been delivered to the incorrect area.

"Root cause was determined to be two-fold. First was the inability prior to implant to place a Foley catheter to fill the bladder allowing a clear definition of the base of the prostate gland. Second was the human error in clear delineation of the prostate gland and alignment of the template prior to seed implant.

"The patient will require further treatment of the prostate gland via re-implantation in order to deliver the appropriate dose. Any effects from the misadministration (medical event) may not manifest immediately and may be difficult to distinguish from the effects of the external beam IMRT treatment that the patient received prior to the March 2006 implant.

"The licensee has implemented a new policy for inexperienced urologists that requires placement of the Foley catheter prior to implanting seeds, thus ensuring clear definition of the base of the prostate and the urethra."

Notified R4DO(Powers) & NMSS EO(Morell)

AGREEMENT STATE REPORT - MISSING SELF-ILLUMINATING EXIT SIGNS

The State provided the following information via facsimile:

"Late last winter and early this spring the general licensee hired a consulting firm to do an inventory of the self-illuminating exit signs in Nebraska. They used the inventory lists of exit signs from the Radiation Control Program in Nebraska and lists from the manufacturers of Isolite (Safety Light) and SRB Technologies to make a comprehensive list of exit signs assigned to Nebraska Licensees. This comprehensive list was taken to each store and compared to the signs that were installed. They made more than one trip to the stores to make sure they had an accurate inventory. They discovered that some signs had been returned to the manufacturer and some signs installed in other Wal-Mart stores in and out of Nebraska. The consultants found 2 missing signs at this location. To help with the inventory in the future, the licensee (1) put a sticker on each tritium exit sign with the 'Item Number' assigned by the State of Nebraska, (2) The sign location was marked on a drawing of the store's floor plan, and (3) The inventory information was compiled and stored in a database. The licensee has discontinued having self illuminating signs installed in their stores in Nebraska. They are also considering replacing the signs with non radioactive material exit signs as they remodel stores in the future. They will continue to do inventories of stores in other states and may find some of the missing signs. The consultants discovered that some contractors took signs from one store to another when they had extra signs left after a construction project. The licensee was unable to determine if the missing signs were installed in this location and then removed during previous remodeling or if the signs were never installed at this location."

Source 1: Manufacturer: SRB Technologies, Model BX-20-GY, Serial number: 27110, 16.51 Curies H-3

Source 2: Manufacturer: SRB Technologies, Model BX-20-GY, Serial number: 270408, 17.51 Curies H-3

Nebraska item number: NE060001

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.

AGREEMENT STATE REPORT - MISSING SELF-ILLUMINATING EXIT SIGNS

The State provided the following information via facsimile:

"Late last winter and early this spring the general licensee hired a consulting firm to do an inventory of the self-illuminating exit signs in Nebraska. They used the inventory lists of exit signs from the Radiation Control Program in Nebraska and lists from the manufacturers of Isolite (Safety Light) and SRB Technologies to make a comprehensive list of exit signs assigned to Nebraska Licensees. This comprehensive list was taken to each store and compared to the signs that were installed. They made more than one trip to the stores to make sure they had an accurate inventory. They discovered that some signs had been returned to the manufacturer and some signs installed in other Wal-Mart stores in and out of Nebraska. The consultants found 4 missing signs at this location. To help with the inventory in the future, the licensee (1) put a sticker on each tritium exit sign with the 'Item Number' assigned by the State of Nebraska, (2) The sign location was marked on a drawing of the store's floor plan, and (3) The inventory information was compiled and stored in a database. The licensee has discontinued having self illuminating signs installed in their stores in Nebraska. They are also considering replacing the signs with non radioactive material exit signs as they remodel stores in the future. They will continue to do inventories of stores in other states and may find some of the missing signs. The consultants discovered that some contractors took signs from one store to another when they had extra signs left after a construction project. The licensee was unable to determine if the missing signs were installed in this location and then removed during previous remodeling or if the signs were never installed at this location."

Source 1: Manufacturer: SRB Technologies, Model BX-20-GY, Serial number: 310254, 17.51 Curies H-3

Source 2: Manufacturer: SRB Technologies, Model BX-20-GY, Serial number: 310289, 17.51 Curies H-3

Source 3: Manufacturer: SRB Technologies, Model BX-20-GY, Serial number: 310290, 17.51 Curies H-3

Source 4: Manufacturer: SRB Technologies, Model BX-20-GY, Serial number: 310291, 17.51 Curies H-3

Nebraska item number: NE060002

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.

AGREEMENT STATE REPORT - MISSING SELF-ILLUMINATING EXIT SIGNS

The State provided the following information via facsimile:

"Late last winter and early this spring the general licensee hired a consulting firm to do an inventory of the self-illuminating exit signs in Nebraska. They used the inventory lists of exit signs from the Radiation Control Program in Nebraska and lists from the manufacturers of Isolite (Safety Light) and SRB Technologies to make a comprehensive list of exit signs assigned to Nebraska Licensees. This comprehensive list was taken to each store and compared to the signs that were installed. They made more than one trip to the stores to make sure they had an accurate inventory. They discovered that some signs had been returned to the manufacturer and some signs installed in other Wal-Mart stores in and out of Nebraska. The consultants found 8 missing signs at this location. To help with the inventory in the future, the licensee (1) put a sticker on each tritium exit sign with the 'Item Number' assigned by the State of Nebraska, (2) The sign location was marked on a drawing of the store's floor plan, and (3) The inventory information was compiled and stored in a database. The licensee has discontinued having self illuminating signs installed in their stores in Nebraska. They are also considering replacing the signs with non radioactive material exit signs as they remodel stores in the future. They will continue to do inventories of stores in other states and may find some of the missing signs. The consultants discovered that some contractors took signs from one store to another when they had extra signs left after a construction project. The licensee was unable to determine if the missing signs were installed in this location and then removed during previous remodeling or if the signs were never installed at this location."

Source 1: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 271458, 11.5 Curies H-3

Source 2: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 279235, 11.5 Curies H-3

Source 3: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 279236, 11.5 Curies H-3

Source 4: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 279237, 11.5 Curies H-3

Source 5: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 279238, 11.5 Curies H-3

Source 6: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 279239, 11.5 Curies H-3

Source 7: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 279240, 11.5 Curies H-3

Source 8: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 279243, 11.6 Curies H-3

Nebraska item number: NE060003

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.

AGREEMENT STATE REPORT - MISSING SELF-ILLUMINATING EXIT SIGNS

The State provided the following information via facsimile:

"Late last winter and early this spring the general licensee hired a consulting firm to do an inventory of the self-illuminating exit signs in Nebraska. They used the inventory lists of exit signs from the Radiation Control Program in Nebraska and lists from the manufacturers of Isolite (Safety Light) and SRB Technologies to make a comprehensive list of exit signs assigned to Nebraska Licensees. This comprehensive list was taken to each store and compared to the signs that were installed. They made more than one trip to the stores to make sure they had an accurate inventory. They discovered that some signs had been returned to the manufacturer and some signs installed in other Wal-Mart stores in and out of Nebraska. The consultants found 3 missing signs at this location. To help with the inventory in the future, the licensee (1) put a sticker on each tritium exit sign with the 'Item Number' assigned by the State of Nebraska, (2) The sign location was marked on a drawing of the store's floor plan, and (3) The inventory information was compiled and stored in a database. The licensee has discontinued having self illuminating signs installed in their stores in Nebraska. They are also considering replacing the signs with non radioactive material exit signs as they remodel stores in the future. They will continue to do inventories of stores in other states and may find some of the missing signs. The consultants discovered that some contractors took signs from one store to another when they had extra signs left after a construction project. The licensee was unable to determine if the missing signs were installed in this location and then removed during previous remodeling or if the signs were never installed at this location."

Source 1: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 228132, 11.5 Curies H-3

Source 2: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 228141, 11.5 Curies H-3

Source 3: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 228109, 11.5 Curies H-3

Nebraska item number: NE060004

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.

AGREEMENT STATE REPORT - MISSING SELF-ILLUMINATING EXIT SIGNS

The State provided the following information via facsimile:

"Late last winter and early this spring the general licensee hired a consulting firm to do an inventory of the self-illuminating exit signs in Nebraska. They used the inventory lists of exit signs from the Radiation Control Program in Nebraska and lists from the manufacturers of Isolite (Safety Light) and SRB Technologies to make a comprehensive list of exit signs assigned to Nebraska Licensees. This comprehensive list was taken to each store and compared to the signs that were installed. They made more than one trip to the stores to make sure they had an accurate inventory. They discovered that some signs had been returned to the manufacturer and some signs installed in other Wal-Mart stores in and out of Nebraska. The consultants found 2 missing signs at this location. To help with the inventory in the future, the licensee (1) put a sticker on each tritium exit sign with the 'Item Number' assigned by the State of Nebraska, (2) The sign location was marked on a drawing of the store's floor plan, and (3) The inventory information was compiled and stored in a database. The licensee has discontinued having self illuminating signs installed in their stores in Nebraska. They are also considering replacing the signs with non radioactive material exit signs as they remodel stores in the future. They will continue to do inventories of stores in other states and may find some of the missing signs. The consultants discovered that some contractors took signs from one store to another when they had extra signs left after a construction project. The licensee was unable to determine if the missing signs were installed in this location and then removed during previous remodeling or if the signs were never installed at this location."

Source 1: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 294689, 11.5 Curies H-3

Source 2: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 294690, 11.5 Curies H-3

Nebraska item number: NE060005

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.

AGREEMENT STATE REPORT - MISSING SELF-ILLUMINATING EXIT SIGNS

The State provided the following information via facsimile:

"Late last winter and early this spring the general licensee hired a consulting firm to do an inventory of the self-illuminating exit signs in Nebraska. They used the inventory lists of exit signs from the Radiation Control Program in Nebraska and lists from the manufacturers of Isolite (Safety Light) and SRB Technologies to make a comprehensive list of exit signs assigned to Nebraska Licensees. This comprehensive list was taken to each store and compared to the signs that were installed. They made more than one trip to the stores to make sure they had an accurate inventory. They discovered that some signs had been returned to the manufacturer and some signs installed in other Wal-Mart stores in and out of Nebraska. The consultants found 3 missing signs at this location. To help with the inventory in the future, the licensee (1) put a sticker on each tritium exit sign with the 'Item Number' assigned by the State of Nebraska, (2) The sign location was marked on a drawing of the store's floor plan, and (3) The inventory information was compiled and stored in a database. The licensee has discontinued having self illuminating signs installed in their stores in Nebraska. They are also considering replacing the signs with non radioactive material exit signs as they remodel stores in the future. They will continue to do inventories of stores in other states and may find some of the missing signs. The consultants discovered that some contractors took signs from one store to another when they had extra signs left after a construction project. The licensee was unable to determine if the missing signs were installed in this location and then removed during previous remodeling or if the signs were never installed at this location."

Source 1: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 324383, 11.5 Curies H-3

Source 2: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 324384, 11.5 Curies H-3

Source 3: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 424395, 11.5 Curies H-3

Nebraska item number: NE060006

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.

AGREEMENT STATE REPORT - MISSING SELF-ILLUMINATING EXIT SIGNS

The State provided the following information via facsimile:

"Late last winter and early this spring the general licensee hired a consulting firm to do an inventory of the self-illuminating exit signs in Nebraska. They used the inventory lists of exit signs from the Radiation Control Program in Nebraska and lists from the manufacturers of Isolite (Safety Light) and SRB Technologies to make a comprehensive list of exit signs assigned to Nebraska Licensees. This comprehensive list was taken to each store and compared to the signs that were installed. They made more than one trip to the stores to make sure they had an accurate inventory. They discovered that some signs had been returned to the manufacturer and some signs installed in other Wal-Mart stores in and out of Nebraska. The consultants found 3 missing signs at this location. To help with the inventory in the future, the licensee (1) put a sticker on each tritium exit sign with the 'Item Number' assigned by the State of Nebraska, (2) The sign location was marked on a drawing of the store's floor plan, and (3) The inventory information was compiled and stored in a database. The licensee has discontinued having self illuminating signs installed in their stores in Nebraska. They are also considering replacing the signs with non radioactive material exit signs as they remodel stores in the future. They will continue to do inventories of stores in other states and may find some of the missing signs. The consultants discovered that some contractors took signs from one store to another when they had extra signs left after a construction project. The licensee was unable to determine if the missing signs were installed in this location and then removed during previous remodeling or if the signs were never installed at this location."

Source 1: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 325286, 11.5 Curies H-3

Source 2: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 325319, 11.52 Curies H-3

Source 3: Manufacturer: Safety Light Corp, Model SLX-60, Serial number: 325320, 11.5 Curies H-3

Nebraska item number: NE060007

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.