United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2009 > July 29

Event Notification Report for July 29, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/28/2009 - 07/29/2009

** EVENT NUMBERS **


45221 45226

To top of page
General Information or Other Event Number: 45221
Rep Org: COLORADO DEPT OF HEALTH
Licensee: CENTURA HEALTH PENROSE - ST. FRANCIS HEALTH SERVICES
Region: 4
City: COLORADO SPRINGS State: CO
County:
License #: 197-01
Agreement: Y
Docket:
NRC Notified By: MARK DATER
HQ OPS Officer: ERIC SIMPSON
Notification Date: 07/22/2009
Notification Time: 14:07 [ET]
Event Date: 07/22/2009
Event Time: [MDT]
Last Update Date: 07/24/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received via fax from the State of Colorado.

"A medical licensee notified the [Colorado Department of Health] of a misadministration during a HDR [High Dose Rate Afterloader] procedure. A positioning error resulted in an estimated dose of 700 Rads to the wrong site.

"No other details are available at this time.

"The Department has initiated an investigation of this incident."

The licensee did not provide the State with an event date and time in the initial event report.

* * * UPDATE AT 1321 EDT ON 07/24/09 BY ERIC SIMPSON * * *

The following information was received by the State of Colorado via fax:

"The [State of Colorado Department of Health] received the following information from the medical physicist who reported the misadministration involving a therapy treatment with a High Dose rate Remote Afterloader (HDR) at Penrose St. Francis Hospital in Colorado Springs, Colorado.

-The date of the misadministration was 7/21/09.

-Because of the error, the dose was delivered to the entrance of the vagina, rather than intrauteral.

-The patient's physician and the patient have been informed of the incident.

-The applicator used in this procedure uses a collet to hold a 3 mm source tube in place. There may have been a problem with the collet, which allowed the source tube to move.

-The licensee instituted corrective actions, which include additional training for all staff involved in HDR therapy treatments, and an additional check of the applicator prior to start of treatment.

"A full report from the medical physicist is expected within the next 7 days.

"No other details are available at this time.

"The Department has initiated an investigation of this incident."

Notified R4DO (Jones) and FSME EO (Villamar).

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.

To top of page
General Information or Other Event Number: 45226
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: DUKE UNIVERSITY
Region: 1
City: DURHAM State: NC
County:
License #: 032-0247-1
Agreement: Y
Docket:
NRC Notified By: JAMES ALBRIGHT
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/24/2009
Notification Time: 16:35 [ET]
Event Date: 07/15/2009
Event Time: [EDT]
Last Update Date: 07/24/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
PATRICE BUBAR (FSME)
ILTAB (via email) ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT INVOLVING THE LOSS OF A CALIFORNIUM-252 SOURCE

On 07/24/09 the State of North Carolina was notified by Duke University that a Cf-252 source could not be located during a mid-July inventory of their TUNL facility.

The following information is a portion of an email forwarded by the State of North Carolina:

"TUNL staff today formally reported the loss of a Californium-252 source:

"(1) Source description: 3.4 microcuries of Cf-252 with an active layer of 8 mm diameter on the platinum backing 15 mm in diameter, 0.2 mm thick. The source was inside an ionization chamber, which was purchased in 1995 from Physikalish-Technische Bundesanstalt, Berlin with an initial activity of 5.17 MBq (86 microcuries; T = 2.645 y)

"(2) Circumstances: A physical inventory of TUNL sources during mid-July determined that this source was missing. A search of the TUNL facility failed to locate this source. Although the investigation is continuing, TUNL staff have concluded that the source is lost.

"(3) Disposition or probable disposition of lost source: This source was incorporated into a piece of equipment (ion chamber) composed of a metal tube with several smaller metal tubes (vacuum lines) coming off of it. TUNL staff suspect that this piece of equipment containing the source may have been left with other scrap items shipped off site for disposal as radioactive waste during the Fall of 2008. However it is quite possible that this ion chamber and the source inside are still somewhere inside the TUNL facility. TUNL staff have been instructed to report if they happen upon it.

"(4) Possible radiation exposure: None under any reasonably probable scenario.

"(5) Actions taken to recover the material: TUNL staff conducted a search of the TUNL facility; the investigation into this incident is ongoing.

"(6) Steps taken to prevent a recurrence: TUNL staff are developing and implementing a series of measures to tighten control over TUNL radioactive sources. The development of these policies and procedures is still underway."

The RSO at the TUNL facility said the lost source is a target foil used in the TUNL linear accelerator (032-247-A1), and it was stored at TUNL. The loss occurred under the Duke University broad scope academic license 032-0247-1 and not the TUNL license. No manufacturer, make, model, or serial number reported at this time (16:45 7/24/09)."

North Carolina Incident ICD 09-30


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.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

Page Last Reviewed/Updated Monday, November 05, 2012
Monday, November 05, 2012