Event Notification Report for November 14, 2011

NEW YORK AGREEMENT STATE REPORT - GAMMAKNIFE THERAPY UNDERDOSE DUE TO MECHANICAL FAILURE OF DEVICE

The following information was obtained from the New York City Office of Radiological Health via email:

"Type of event: Therapy, gammaknife

"Description of event: Patient was being treated by gammaknife Model C-23004 for a meningioma. Halfway through, the treatment was automatically terminated. It was discovered that the latch that fastens the immobilizing frame of the head to the couch failed. Termination of treatment resulted in an underdose of more than 50% below the prescribed dose for that fraction. This was the third of three patients who were being treated at about that time. The first two patients were treated without incident.

"Discovery of Event: Event was discovered when treatment was automatically terminated in the course of treatment.

"Effect on Patient: In the opinion of the responsible physician, there are no expected sequelae for this patient as a result of this event.

"Root Cause of Event: The root cause of this event was mechanical failure. There was not found to be any computer failure involved.

"Actions Taken to Prevent Recurrence of Event: Replacement of latch mechanism.

"Inspection Results: An inspector from the [NYC] Office of Radiological Health conducted an inspection on 11/17/11. The inspector found the circumstances of the event to be as described above.

"Any Issuance of Violations: No formal violation was issued.

"This case is considered closed."

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 - THEFT OF A TROXLER DENSITY GAUGE

The following report was received from the Mississippi Division of Radiological Health (DHR) via e-mail:

"The licensee's RSO contacted DRH to report the theft of their Troxler Model 3440 (S/N 22563) nuclear gauge that was secured in the back of their white marked pick-up truck parked six spaces from the front entrance of the Wal-Mart [located in Meridian, MS]. The two gauge cables were cut and the gauge was taken out of the truck bed. All required shipping documentation was stolen out of the unlocked cab of the truck. The gauge and gauge paperwork were estimated to have been stolen around 1820 [CST]. The gauge was stored in the yellow plastic transport case with Radioactive Yellow II labels attached. The yellow plastic transport case had two locks on the outer container and two cables threaded through the top handle and locked with two separate locks on each separate eye hook.

"Meridian City Police were immediately notified by the licensee. Licensee notified Mississippi Emergency Management Agency (MEMA) at 1940 [CST]. MEMA contacted DRH at 1955 [CST]. DRH notified Department of Homeland Security (DHS) who then notified FBI.

"DRH performed an inspection and investigation on November 16, 2011 at Terracon Consultants, Inc., in Ridgeland."

The gauge contained the following sources: Cs-137 (S/N 75-4297) (8 mCi); Am-241:Be (S/N 47-18403) (40 mCi)

Mississippi Report MS-11006

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