Event Notification Report for December 13, 2018

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA LOST BY COMMERCIAL CARRIER

The following report was received from the state of Florida via e-mail:

"Received a call from Versa Integrity Group to report a missing Ir-192 radiography camera. The device was shipped from Sanford, Florida via [commercial carrier] on 11-29-18 in route to Corpus Christi, Texas, but never arrived. The last location that [the commercial carrier] can confirm the location of the package was Memphis, Tennessee. (Source information - model: A424-9, S/N: 62109G)."

The camera had a 330 GBq Ir-192 source.

The licensee contacted the commercial carrier on 12-10-18, to inquiry about the shipment and was told it was delayed. The licensee recontacted the commercial carrier on 12-13-18 and was told the package could not be located.

Florida Incident: FL18-153

* * * UPDATE FROM ART TUCKER TO HOWIE CROUCH AT 1556 EST ON 12/13/18 * * *

The state of Texas also reported the same event since their licensee was the intended recipient. The Texas Department of State Health Services will be contacting the state of Florida about this event.

Texas Incident: 9645

Notified R4DO (Taylor) and NMSS Events Notification group (email).

* * * UPDATE AT 1345 EST ON 12/21/2018 FROM ART TUCKER TO MARK ABRAMOVITZ * * *

The following information was received via fax:

"At 12:39 PM [CST] on December 21, 2018, the licensee contacted the Agency [Texas Department of State Health Services] and stated they had received an email from [the commercial carrier] stating the exposure device would be delivered to the facility in Corpus Christi by 1645 [CST] hours today."

Texas Incident: I-9645

Notified the R1DO (Jackson), R4DO (Alexander) and NMSS (via e-mail).

* * * UPDATE AT 1703 EST ON 12/21/2018 FROM ART TUCKER TO TOM KENDZIA * * *

The following information was received via fax:

"The licensee contacted the Agency [Texas Department of State Health Services] at 1550 hours and reported they had received the exposure device. The licensee stated they would provide additional information after they completed their investigation. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident: I-9645

Notified the R1DO (Jackson), R4DO (Alexander) and NMSS (via e-mail).

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)

AGREEMENT STATE REPORT - REPORT OF LOST I-125 SEED DURING MEDICAL PROCEDURE

"Nebraska Department of Health and Human Services, Office of Radiological Health was notified on December 21, 2018 at 8:50 am CST by the Radiation Safety Officer (RSO) from Regional West Medical Center (Nebraska license 21-01-03) that one I-125 seed is lost and still missing at this time. The I-125 seed was part of a manual brachytherapy procedure that involved one hundred permanently implanted I-125 seeds in the patient's prostate. The procedure occurred in a surgery suite at approximately 9 am MST, the patient was then transported to a recovery room and then to a CT suite to confirm the placement of the seeds at approximately 12:19 pm MST. During the review of the CT, the licensee observed that only ninety nine seeds were implanted. The licensee then conducted a search for the missing I-125 seed.

"During the search of the missing I-125 seed on December 13, 2018, licensee staff surveyed the surgical suite and recovery room of the patient. The licensee staff were not able to find the missing seed. During the survey, licensee staff also questioned the nursing staff and it was noted that a nurse emptied a catheter bag into a toilet shortly following the completion of surgery. Licensee staff believe that the missing I-125 seed may have been flushed and disposed in the sanitary sewage system.

"The missing I-125 seed was a Bard Medical product, serial number 7815544SO, containing 283 uCi and was one of many seeds preloaded into a needle to be injected into the patient. On December 13, 2018 at 9:30 am CST, the RSO was contacted to report the search results in the adjacent hallways, the CT suite, and if possible, any sewage holding areas. The RSO has dispatched staff to conduct a new search of all areas and transport beds that the patient was in and in contact areas. The RSO expects this to be completed later in the day of 12/21/2018.

"The State is awaiting the results of this new survey and will be following up with the licensee and US NRC."

Nebraska Report: NE-18-0009

* * * UPDATE AT 1721 EST ON 02/07/2019 FROM LARRY HARISIS TO JEFF HERRERA * * *

The following update was received from the Nebraska Department of Health and Human Services (DHHS) via email:

"On 01/16/2019, Nebraska DHHS Office of Radiological Health staff arrived at the licensee's facility. Discussions, reenactments, radiological surveys, and presentations were performed and given to assess if the I-125 seed was disposed of in the sanitary system. A review of the licensee's training of oncology staff and nursing personnel, policies and procedures for specific seed implantation for oncology and nursing staff, and interviews of all involved personnel were completed.

"It was determined that all 100 I-125 seeds were implanted into the patient as ordered and the bladder was verified as emptied by a cystoscope after removing an inflated balloon to prevent seeds from entering the bladder. After the inflatable balloon device was removed from the patient, a seed near the urethra was dislodged and entered the urethra then into a urinary catheter bag. When the oncology personnel arrived at the patient's recovery room, they noticed that the urinary catheter bag was abnormally low. Oncology personnel found that a nurse in the recovery room emptied the urinary catheter bag without approval from Oncology personnel, inadvertently disposing of the seed in a sink in the recovery room. Oncology personnel surveyed the surgical suite, recovery room, and sink with no results above background. A review of the policies and procedures of radioactive seed implantation with the nursing staff was also completed.

"The licensee's implementation of corrective measures to prevent a reoccurrence will be reviewed on the next inspection."

Notified the R4DO (Werner) and NMSS Events (via email).

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.

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