Event Notification Report for April 13, 2015

LOST/MISSING CALIBRATION SOURCE

The following was received by email:

"Notification from Master Material License [MML] No. 42-23539-XXAF, issued to the Department of the Air Force. The following report of a possible lost or missing source likely involves a source not specifically licensed under the MML:

"On 13 April 2015 at 1030 hours, an officer newly assigned to Cannon AFB [Air Force Base] discovered a source on the radioactive material inventory he could not physically locate. The source was listed as an Am-241 check source for a Smiths model 1500 instrument, with no information provided except for a previous storage location. The officer could not locate any records of disposition for this source, but continues to investigate disposition records for the base. The officer interviewed a predecessor who asserted the Am-241 line item on the inventory could be a clerical error.

"The licensee contacted Smiths Detection which to date could not verify the existence of a Smiths Model 1500 or an Am-241 check source.

"They are unaware of any exposures at this time.

"The base will ensure complete/accurate data entry for radioactive material inventories and subsequent verification of inventory through physical 'eyes-on' inventories."

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

AGREEMENT STATE REPORT - RADIUM SOURCE FOUND

The following report was received via e-mail:

"Reported by Weld County DPHE [Department of Public Health and Environment] on behalf of Vista Ridge Academy, Erie, Colorado on Monday April 13, 2015.

"The material was discovered in a glass vial marked 'radium dust' which was verified as Radium 226 using a portable MCA (IdentiFINDER 2, S/N 910383-80, background 0.01 mrem/hr). The readings on contact and at one foot from the vial were 2.8 mrem/hr and 0.1 mrem/hr respectively. Due to the elevated nature of the readings, it was determined shielding should be put in place to protect individuals from exposure. The material was placed in plastic bags to contain the material in the event the lid falls off or the glass is broken. Additionally, ceramic bricks were used to build a temporary storage area for the vial to reduce the exposure in the area. The exposure on the outside of the brick shielding was 0.3 mrem/hr on contact. The material is stored in a secured closet. The mass of the contents in the vial were determined to be 204.5 grams with an approximate volume of 84.78 cubic centimeters. (The mass was determined using a school scale and a similar empty vial. The volume was determined by approximation of the diameter and height of the material in the vial.)

"Surveys were performed around the work bench area, storage shelf and a removable contamination wipe was done on the vial. It was determined during the site visit no contamination was present in the lab or storage area indicating no exposures to students or staff.

"Using the information gathered and making a few assumptions about efficiency, there is an estimated 50 to 100 uCi in the vial.

"Report ID number: CO15 - I15 -12

"A provisional license will be issued until the material can be properly disposed."

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

POTENTIAL OVEREXPOSURE TO RADIOGRAPHER

A radiographer dropped his film badge on the floor before his first exposure. The floor was approximately three feet below the collimator for a two minute exposure. After his second exposure, he found his film badge. The licensee's RSO had the film developed with a result of 14.069 Rem. The source was Ir-192 at 78.6 Ci. Estimated dose by the licensee and REAC/TS expected a dose of closer to one and a half Rem. The licensee is continuing his investigations because of this discrepancy.

MANUAL REACTOR SCRAM INITIATED

"Following a pre-planned scram for entry into the U2 Refueling Outage, the 'B' Reactor Protection system (RPS) was unable to be reset due to a deficiency with the '2H' Intermediate Range Power Monitor. Due to this failure to reset RPS, a manual full scram was initiated as required by plant procedures."

The licensee notified the NRC Resident Inspector.

DUMMY WIRE JAMMED DURING BRACHYTHERAPY TREATMENT

A patient was receiving brachytherapy treatment using a SAVI device that used 11 channels. The patient was treated with 2 channels when the dummy wire jammed in the out position. The patient was prescribed a fractional dose 340 cGy, but received only received 60 cGy.

There are no adverse effects expected to the patient. The prescribing physician has been informed.

The licensee has contacted a company to repair the device and has ceased all operations until repairs can be made.

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 - INCORRECT DOSE PRESCRIBED BUT CORRECT DOSE ADMINISTERED

The following report was received from the Commonwealth of Pennsylvania via email:

"Notifications: The Licensee notified the Department April 1, 2016 of an event that occurred on April 13, 2015. It was discovered almost a year later upon routine review of written directives at the hospital. It is reportable under 10 CFR 35.3045.

"Event Description: A Xofigor patient was scheduled for their 6th and final treatment on April 13, 2015. The Authorized User (AU) prescribed 0.98 millicurie (mCi) on the written directive (WD). On the prescription form from the radiopharmacy, the 'dispensed amount' of Ra-223 was labeled as 99.40 microCuries (or 0.0994 mCi). The Nuclear Medicine Technologist measured '0.099 mCi' in the dose calibrator just before injecting the Xofigor into the patient (intravenously). The technologist failed to observe that the AU prescribed an activity of 0.98 mCi making the percent error between the measured vs. prescribed activity at -89.9% based upon what was documented in the WD. The hospital believes the intent of the AU was to prescribe '0.098 mCi' which is a typical dose; however, they cannot directly confirm that with the AU since the AU is no longer employed by Geisinger Health System. Another Geisinger AU who is qualified to prescribe Xofigor confirmed that 0.098 mCi would be the correct amount when calculated from the patient's weight. Consequently, if the intent was to prescribe 0.098 milliCuries, there would be no expected harm to the patient as they received the proper Xofigor activity.

"Cause of the event: Human error.

"Actions: None at this time. The licensee will submit a final report which will provide corrective actions. Notifying the patient would serve no beneficial purpose."

PA Report #: PA160012

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.