Event Notification Report for November 26, 2020

AGREEMENT STATE REPORT - MEDICAL REPORT - UNDERDOSE

The following was received from the State of Kentucky via email:

"The Kentucky Radiation Health Branch was notified by the Radiation Safety Officer of a medical event at Norton Hospital Interventional Radiology Downtown Campus, Louisville KY (RML No. 202-031-26). Deviation from Y-90 Therasphere treatment dose to a patient was immediately identified due to a leak between the administration kit and the microcatheter used in administration of the dose. The situation was remedied by tightening the connection at the junction, and no further loss of material was observed. Spillage was confined to patient drape and follow-up surveys for external contamination on the patient and staff present were conducted. The room and staff were subsequently cleared of any radioactive contamination. The patient dose assessment was estimated using the patient waste and the spill waste and it was determined that the delivered dose was 93 Gy which was 68 percent of the prescribed dose of 135 Gy. Initial root cause analysis indicated that the administration set received from the manufacturer was a different kit from the previous set, and a mismatch resulted in a leaky junction. The licensee has contacted the manufacturer (Boston Scientific BTG) to resolve this situation."

Kentucky Event Report ID No.: KY200006

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.

EN Revision Imported Date: 11/30/2020

EN Revision Text: AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE

The following was received from the state of Texas (the Agency) by email:

"On October 1, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that a Troxler model 3430 moisture\density gauge containing a 40 milliCurie americium-241 source and an 8 milliCurie cesium-137 source was stolen from an employee's truck. The truck was parked at the employee's residence and when they came out to go to the job site they found both chains securing the gauge in the truck were cut and the gauge was missing. The RSO stated they had notified local law enforcement and the fire department.

"The RSO stated their management group was searching social media looking for the gauge. The RSO stated they currently have people in the field looking for the gauge. The RSO stated the gauge operating arm was locked. The gauge would not create an exposure risk to any individual unless the lock was cut off the operating arm and the cesium source exposed. Additional information will be provided as it is received in accordance with SA-300."

TX Incident # 9803.

* * * UPDATE ON 11/27/2020 AT 1827 EST FROM ART TUCKER TO JEFFREY WHITED * * *

The following was received from the Agency via email:

"On November 27, 2020, the Agency was notified that the gauge was recovered by the Austin, Texas Police Department. The licensee has been contacted and is arranging to pick up the device. Addition information will be provided as it is received in accordance with SA-300."

Notified R4DO (Kozal), NMSS Event Notification (email), ILTAB (email), and CNSNS Mexico (email).

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