Event Notification Report for July 16, 2020

AGREEMENT STATE REPORT - DAMAGED GAUGE

The following was received form the California Radiologic Health Branch (RHB) via email:

"On 7/17/2020, licensee's RSO [(Radiation Safety Officer)] contacted RHB to report an incident in which a portable nuclear gauge (Humboldt 5001EZ SN: 2919, 11 mCi Cs137, 44 mCi Am241:Be) was damaged by a construction truck at approximately 2330 PDT on 7/16/2020. The RSO secured the gauge after notification by the gauge technician and transported the gauge to the licensee's permanent storage location. The RSO determined and confirmed to RHB that the source rod was able to be retracted into the shielded position after the incident. The RSO performed a radiation survey and reported readings of 0.099 mR/hr at 1 meter. RHB will be following up with this investigation."

California 5010 Number: 071720

AGREEMENT STATE REPORT - MISADMINSTRATION OF MEDICAL TREATMENT

The following was received from the State of Utah, Department of Environmental Quality, Division of Waste Management and Radiation Control:

"Misadministration with external beam radiation therapy, the licensee (Utah Cancer Specialists) delivered 300 cGy per site, per day, over two treatments, as follows: Two sites were treated incorrectly at 1000 MDT on July 16, 2020 in the 3rd lumbar area and the right kidney. One site was treated incorrectly at 1530 MDT on July 17, 2020 in the 3rd lumbar area while the right kidney was treated correctly.

"It was discovered by way of a cone beam CT in preparation for the kidney treatment where the misalignment was observed. The misalignment was made due to setting up at incorrect tattoos."

Utah Event Number will be provided in a later report.

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 - MEDICAL MISADMINISTRATION

The following was received from the Florida Bureau of Radiation Control (BRC) via email:

"On July 16, 2020, a 54 year old man was mistakenly provided two doses of Tc-99 Sestamibi for heart stress test. Two doses were administered with a total activity of 41.6 mCi, estimated dose of 7.49 R, to the intestinal wall. The RSO [(Radiation Safety Officer]) reports that standard verification process for patient identification prior to dosage was not followed. Patient and patient's cardiologist have both been notified, no effects of the mis-dose are expected.

"The RSO will provide additional info in the 15 day letter to BRC. Licensing and Technology will be tasked to investigate."

Florida Incident Number FL20-081

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 - LOST EXIT SIGNS

The following information was provided by the Colorado Department of Public Health and Environment via email:

The licensee discovered twelve tritium exit signs were lost. The exit signs are SRB Technologies Model BR20BK containing 20 Ci of tritium (H-3) each. This is being reported under Colorado Regulations Section 4.51.1.1 (10 CFR 20.2202(a)(1)(i)).

Colorado Incident No.: CO220043

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