Event Notification Report for January 05, 2021

AGREEMENT STATE REPORT - LOST GAUGE

The following was received from the Ohio Department of Health via email:

"While conducting the annual General License inventory, the licensee discovered a missing gauge. Attempts to locate the gauge were not successful. It is believed that gauge was inadvertently sent to a metal scrap yard. The gauge is an Industrial Dynamics Model FT-50 [(s/n: 116107)] containing a 100 mCi Am-241 sealed source."

Ohio Item Number: OH 2020-058

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 - UNDERDOSE TO PATIENT UNDERGOING RADIATION TREATMENT

The following information was received from the Texas Department of State Health Services (the Agency) via email:

"On December 30, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that a medical event had occurred at their facility. A patient was to receive a single fraction of 700 centigray from a high dose rate remote afterloader unit (HDR) but received a dose of 525 centigray. The patient was notified of the error and the RSO stated they were in the process of notifying the physician. The RSO stated that there would be no adverse effects to the patient from the error. The RSO was unsure of the manufacturer and model of the HDR unit and the activity of the iridium source that was used. Additional information was requested by the Agency. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: 9819

WHOLE BODY DOSIMETRY INDICATES EXPOSURE OF OVER 11 REM

On December 29, 2020, Yale University received notification from their dosimetry vendor that one of their employee's badge indicated a whole body dose of 11,843 mRem for the October 2020 wear period. The employee works in the radiopharmaceutical area of the University.

When the employee was interviewed, they admitted that they could not locate their whole body badge when swapping out the October badges for the November badges. The employee found their badge on November 17, 2020 in the fume hood where they believed it fell off their lab coat when cleaning the fume hood for maintenance.

The employee's ring badges for the October wear period was 73 mR (left) and 63 mR (right). November ring badge readings were about the same with November whole body dose of zero. During the October/November timeframe, there were no abnormal surveys or area radiation monitor alarms. No other employee badge read abnormally high.

Yale intends to perform an extensive investigation after the holidays, they believe the October badge was dosed while misplaced in the fume hood for the two-week period is was missing.

The licensee will update this event, if required, once the investigation is complete.