Event Notification Report for January 07, 2015

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following was received via email:

"This morning, the Columbus, GA Police Department was dispatched to the Building and Earth Sciences business located at 5045 Millgen Court in Columbus. It was reported that unknown person(s) had stolen a Model 3440 Nuclear Density Gauge Serial Number 22740. The gauge had been locked and secured in the back of a truck in the facility and the individual(s) had taken bolt cutters and cut the chains securing the device. No further information is available at this time."

The stolen gauge contains approximately 8 mCi of Cesium-137 and 40 mCi of Americium-241.

A regional law enforcement bulletin was issued and the Columbus, GA and Atlanta, GA FBI field offices were notified.

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

AGREEMENT STATE REPORT - DOSE ADMINISTERED EXCEEDED 50 REM

The following information was provided by the State of California Department of Public Health - Radiological Health Branch (RHB) via email:

"On 01/14/15, RHB received an email from the RSO reporting a Medical Event. On 1/7/15 a patient was scheduled for a thyroid uptake scan. Instead of the prescribed dose of 300 microcuries of Sodium Iodide 123, 3.69 mCi [3690 microcuries] of the isotope was administered to the patient. Due to quality of the scan, the error was noted. An initial calculation performed on 1/8/15 indicated target organ [dose] exceeding 50 rem. On 1/9/14, another calculation performed by the consulting physicist using patient's actual measured uptake values, the target organ [dose] was deemed less than 50 rem and it was decided to be non-reportable. On 1/13/15, the chief of Nuclear Medicine reviewed the reference source and contacted the same physicist to review his calculations, and the physicist realized that he made an error in calculations, and informed the facility that the organ dose exceeded 50 rem. On 1/14/15, the Kaiser Medical Physicist confirmed the [dose] to be 53.6 rem to the thyroid, and the RSO notified RHB of the Medical Event. RHB will be following up on this matter."

CA Event Report Number: 011415

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.

RECEIVED DOSE DIFFERED FROM PRESCRIBED DOSE OF I-125

On December 17, 2014, a patient had a 123 microCurie I-125 seed implanted in her breast as part of a treatment plan for non-palpable breast cancer. The treatment plan was to remove the seed after 5 days.

Due to illness, the patient was unable to return to the hospital to have the seed removed until January 7, 2015. This resulted in the patient receiving an 83.6 cGy exposure versus the prescribed 18.4 cGy exposure.

The prescribing physician and the patient were notified. No permanent damage due to the exposure is expected.

The licensee coordinated this report with NRC Region 1 Senior Health Physicist Penny Lanzisera.

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.

* * * UPDATE FROM RUTH SHANLEY TO CHARLES TEAL AT 1529 EST ON 2/3/15 * * *

The licensee called to report two additional patients whose dose exceeded 50 cGy.

The first patient was not medically cleared for the procedure. The patient received 57.9 cGy instead of the prescribed dose after 5 days of 21.8 cGy of I-125.

The second patient refused to undergo the procedure until genetic testing was completed. The patient received 54 cGy instead of the prescribed dose after 5 days of 20.3 cGy of I-125.

The licensee will modify their procedures to wait until patients are medically cleared and wait until all other testing is done prior to undergoing the procedure.

Notified R1DO (DeFrancisco) and NMSS Events Notifications via email.