Event Notification Report for June 23, 2020

LEAKING SOURCE FROM AIRCRAFT RADIUM DIAL

The following summary of information was received via email:

On June 23, 2020 at approximately 1130 [CDT], the Permit Radiation Safety Officer (PRSO) was working on a J-79 engine and proceeded to survey his work area. During the survey, he found measurements indicating contamination on a nearby table that contained an instrument dial. He did a direct measurement of the Oxygen Pressure Indicator dial, which is approximately 2 inches in diameter and found approximately 7000 Counts Per Minute (CPM) direct reading. The PRSO surveyed the covering over the table on which the dial was on and found approximately 100 CPM with the Ludlum 44-9 pancake style Geiger Muller (GM) probe. The area of the contamination he found was about the size of the probe area. Surveys of the cockpit and surrounding areas were all less than 20 disintegrations per minute (dpm)/100 square centimeter loose and 100 dpm/100 square cm total for Radium-226 in accordance with the Acceptable Surface Contamination Levels. The dial was removed from a restored aircraft in a publicly accessible part of the museum. The aircraft was originally surveyed in 1989 and the presence of the radium dial was not detected. Therefore, no radiological controls were implemented to prevent any possible public exposure. The quantity of Radium-226 was estimated at 2 microCuries for the dial. The dial was turned into the Air Force Radioactive Recycling and Disposal center for disposal. The contaminated portion of the table was cut out and disposed of. The open cockpit was surveyed to verify no presence of Radium-226. Any cleaning equipment for the cockpit and surrounding area of the aircraft were controlled and moved to a radioactive storage area.

The licensee contacted Region IV.

AGREEMENT STATE REPORT - SUSPECTED DOSE TO WRONG ORGAN

The following is a summary of email received from the Oklahoma Department of Environmental Quality (OK DEQ):

OK DEQ was just informed that yesterday, June 23, 2020, a medical event may have occurred involving a patient undergoing radiation therapy to the vagina. The treatment plan called for three (3) fractions delivered by a High Dose Rate (HDR) afterloader. After the first fraction was administered, the therapist noted the presence of fecal matter on the applicator. The licensee is assuming that the applicator was placed in the patient's rectum instead of the vagina. The treatment plan estimated a dose of 0.85 Sv to the rectum due to the procedure. The licensee estimates the actual dose delivered, assuming the applicator was in the rectum, to be 1.5 Sv. The licensee is the University of Oklahoma Health Science Center, OK-03176-01. This is a Type A medical broadscope license. OK DEQ will provide more information as it becomes available.

* * * UPDATE ON 07/21/2020 AT 1549 EDT FROM LIBBY MCCASKILL TO OSSY FONT * * *

The following update was received from the OK DEQ via email:

OK DEQ is correcting the licensee name and license number. Initially, they were reported as the University of Oklahoma Health Science Center, OK-03176-01. The correct licensee is OU Medicine, Inc., License No. OK-21035-01.

Notified R4DO (Drake) and NMSS Event Notification via email.

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 - HIGH DOSE RATE TANDEM APPLICATOR BROKEN DURING TREATMENT

The following was received via E-mail from the State of Texas:

"On June 23, 2020, the licensee reported that at approximately 0900 CDT, a Medical Event occurred at its facility. The event involved a patient receiving an High Dose Rate (HDR) cervix treatment with a Nucletron Model microSelectron using a tandem and ring. The device contained a 5.191Curie Iridium-192 source. After the treatment was completed and the device was removed, it was discovered the tandem had broken into two pieces. The licensee stated it is unknown where the source was positioned during the treatment. The licensee reported no warnings or errors from the machine were recorded from either the check source or the treatment cable. The licensee stated the source was in the patient for a total of 564.7 seconds. The source was in the tandem a total of 355.2 seconds of that total time. The licensee stated the physician has been notified, but was not sure if the patient had been notified. The licensee stated they were still investigating what occurred and will provide more specific information as it is discovered. Additional information will be provided as it is received in accordance with SA300."

Texas Incident No.: 9774


* * * UPDATE FROM ART TUCKER TO DONALD NORWOOD AT 0902 EDT ON 6/30/2020 * * *

"The break in the tandem occurred about four inches from the end of the tandem. A picture provided by the licensee shows the break at the beginning of the bend in the tandem on the insertion end at the start of the ring. The licensee stated using the location of the guide wire, which they could track, it now appears that the source tracked next to the tandem and that the exposure occurred only to the intended tissue. The manufacture is investigating the event with the licensee. Additional information will be provided as it is received in accordance with SA300."

Notified R4DO (Silva) and NMSS Events Notification E-mail group.