Event Notification Report for November 19, 2019

AGREEMENT STATE REPORT - DOSE LESS THAN PRESCRIBED DELIVERED TO TREATMENT SITE

The following information was received via E-mail:

"On November 20, 2019, the licensee notified the Virginia Office of Radiological Health (ORH) that a medical event occurred as a result of treating a patient using a High Dose Remote Afterloader Unit (HDR). According to the written directive, 18 Gray (Gy) dose to the neck, in three (3) fractions of 6 Gy, was prescribed. On November 19, 2019, the first of the three fractions was delivered. However, the dose was delivered at 91.5 cm instead of the intended 118.1 cm. This resulted in a dose to the treatment site of approximately 0.3 Gy.

"The report indicated that the error was discovered on November 20, 2019 at 0830 EST after the medical physicist re-measured the guide tube and catheter. It was discovered that the guide tube and catheter were not connected properly and this caused the dose to be delivered at 91.5 cm.

"The prescribing physician and the patient were notified immediately (at 0915 EST).

"ORH will review the licensee's written report and determine additional actions to be taken."

Virginia Event Report ID No.: VA-19-005

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.

AGREEMENT STATE REPORT - STUCK SHUTTER

The following was received via email from the Louisiana Department of Environmental Quality (the department):

"On 11/21/2019, at 1245 [CST], [the licensee] called [the department] to report that a stuck shutter [model - OHMART SH-F1 with 50 mCi of Cs-137] was found during the annual shutter check test. An equipment malfunction, which was a stuck shutter, was found on 11/19/2019, at approximately 1030 [CST] at BASF Corporation Chemicals Division. The shutter is stuck in the open condition and does not affect operation.

"BASF has contacted BBP Sales, Inc. to come in to replace the handle and any other parts needing replacing."

Event Report ID No.: LA190013

AGREEMENT STATE REPORT - DENSITY GAUGE DAMAGED

The following was received from the State of Arkansas via email:

"The [Arkansas] Department [of Health] received notification on November 20, 2019, from licensee Professional Services Industries, Inc., that a Troxler gauge model 3430 had been struck by a skid-steer while performing routine measurements at a road construction site. The gauge was not being used at the time it was struck and the sources were in the shielded position.

"Upon review of the event, it was noted that the technician quickly created a thirty foot containment barrier and notified his company's Radiation Safety Officer (RSO). The RSO for Professional Services Industries mobilized to the event location.

"Once onsite, the RSO surveyed the immediate area around the damaged gauge and the gauge itself. The RSO determined that no radiation measurements were found to be above normal levels for that model of portable gauge. A leak test of the sealed sources was immediately conducted and the remnants of the gauge were collected and returned to the permanent storage location on November 19, 2019. The RSO and the Authorized User operating the portable gauge were wearing dosimetry.

"The Arkansas Department of Health considers this investigation open pending receipt and review of the licensee's 30 day report."

Arkansas Event No.: AR-2019-005

* * * UPDATE 0N 1/16/2020 AT 1035 EST FROM CHRIS TALLEY TO THOMAS KENDZIA * * *

The following was received from the Arkansas Department of Health via email:

"Upon review of the licensees 30 Day Report, received December 26, 2019, it was noted that the dosimetry badges worn by the Authorized User and RSO during the retrieval and transportation of the sources showed no measurable dose. The dosimetry badges worn were issued to the users on October 15, 2019 and the event occurred on November 19, 2019.

"The report contained leak test results for the sources taken immediately following the event, November 19, 2019. The results for the leak tests in both instances were measured to be below 185 Bq (0.001microCi), considering the sources to be non-leaking sources.

"The company conducted mandatory safety meetings with all staff in the PSI-Sherwood office who work with the portable gauges as a result of the event. Topics discussed during the meetings and e-mail included radiation safety, gauge security, and gauge control. The company also has re-trained the individual authorized user responsible for the gauge during the event via a 're-entrance' exam.

"The radioactive sources and associated nuclear gauge remnants were returned to the manufacturer for disposal. The sources are now listed under North Carolina Radioactive Materials License #032-0182-1.

"The [Arkansas] Department [of Health] considers this event to be closed, providing that no new information is received."

Notified the R4DO (Young) and the NMSS Events Notification group (email).