Event Notification Report for August 03, 2009

AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE

"On August 3 the [Illinois Emergency Management] Agency's Radiation Duty Officer was contacted after normal business hours and advised that a portable moisture density gauge had been reported stolen from a vehicle at approximately 5 PM that same day. The caller was an officer with the Chicago Police Department who was investigating the event. The vehicle had been parked on the south side of Chicago, IL in front of the field technician's house at the time of the theft. The company's [H.H. Holmes] radiation safety officer contacted the [Illinois Emergency Management] Agency the next morning to report additional details of the theft. Evidence at the crime scene showed that the door to the SUV had been jimmied open with a crowbar and the chain which was looped through the handles of the transport case in the back of the vehicle had been pried from the case such that the lid could be opened and the gauge removed. Additional tools, a cell phone, the radio and personal equipment was also stolen from the vehicle. The company was in the process of acquiring additional information and compiling crime scene photos to include with the formal report.

"Pending receipt of that report and follow up action from the Chicago Police Department, the [Illinois Emergency Management] Agency is continuing its investigation and considers the matter open."

The stolen gauge was manufactured by Troxler (model number 3440, serial number 34692). The gauge contained a sealed source with 0.008 Ci of CS-137 (serial number 102112) and another sealed source with 0.04 Ci of Am-Be (serial number 47-30325).

Illinois report number - IL0900059

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.

AGREEMENT STATE REPORT INVOLVING SEVENTEEN LOST TRITIUM EXIT SIGNS

The State of Nebraska was notified by a Bed Bath & Beyond representative that they are unable to account for a total of 17 tritium exit signs (which are general licensed materials). These 17 signs were part of an order that went to three separate Bed Bath & Beyond store locations in the Omaha, NE area. The Bed Bath & Beyond representative informed the state that Bed Bath & Beyond has performed an extensive search and considers the signs not to be present at the stores.

- Sixteen (16) signs are Safety Light Corporation Model SLX60 and contain 11.5 Ci/each H-3. The serial numbers of these 16 missing signs are as follows: 302790, 302792, 302793, 283015, 302799, 302800, 302810, 302803, 397719, 397720, 397721, 397722, 397725, 397726, 397728, and 397730.

- One (1) sign is Safety Light Corporation Model 2040 and contains 11.5 Ci H-3. The serial number for this sign is #257964.

NE Item Number NE090012 (Store #771-GL0634), NE090013 (Store #1021-GL0654) and NE090014 (Store #1184-GL0605).

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

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

AGREEMENT STATE REPORT - LATE REPORTING FOR DIAGNOSTIC MISADMINISTRATION

The following information was provided by the State of Georgia via email:

"Licensee contacted the Department [Georgia Radioactive Materials Program] via telephone on 8/12/09 reporting that a patient who underwent a nuclear cardiology treadmill stress test on 8/3/09 resulted in an embryo/fetus exposure greater than 500 mRem. The Department received a report from the licensee on 8/14/12 describing that prior to treatment the patient declared to the licensee that she was not pregnant and the licensee followed in house protocols in which all female patients under the age of 55 are asked if they are currently pregnant or breastfeeding. In the event that a patient is unsure the licensee postpones testing until a negative pregnancy test can be obtained. The patient later informed the licensee of her pregnancy on 8/10/09. Isotopes and activity administered to the patient were as follows: Tc-99m 28.2 mCi & Tl-201 3.62 mCi with a Total Activity of 31.82 mCi. RSO for the licensee & consulting medical physicists conducted a dose determination and the conclusion was that the embryo/fetus did receive an effective dose equivalent in excess of 500 mRem. The results were forwarded to the patient's OBGYN."

This was a diagnostic misadministration that did not involve contamination.

* * * UPDATE FROM TRAVIS CARTOSKI TO VINCE KLCO ON 1/30/13 AT 0943 EST* * *

The following information was excerpted from a received facsimile:

"[The update is concerned with] the radiopharmaceutical dose administration that a female patient recently received at the testing facilities. It was subsequently determined that this patient was 4 months pregnant. The patient received two dose administrations, one dose of Tc-99m - Myoview for the Stress Myocardial Perfusion scan and one dose of Tl-201 as Thallous Chloride for the Rest Myocardial Perfusion scan. The patient received 28.2 mCi of Tc-99m-Myoview and 3.62 mCi of TI-201.

"The dose to the conceptus was approximately 1.97 Rad. Determination of dose is limited by patient habitus and physiology."

Notified the R1DO (Bellamy) and FSME Resources.

Report: GA-2009-12i

NMED# 090811