Event Notification Report for March 30, 2021

AGREEMENT STATE REPORT - MEDICAL EVENT (INCORRECT DOSE LOCATION)

The following report was received from the state of North Dakota Department of Environmental Quality via email:

"Received a phone call at 1600 [CST] on Thursday March 18 that a PET/CT patient was injected with 10 milliCuries of Fluorine-18 and it was found that all of the injected Fluorine-18 had infiltrated in the arm of the patient [rather than being dispersed throughout the body]. Patient's arm was imaged by PET scanner to confirm dose was in fact infiltrated in the arm. Dose calculations are being performed by licensee to determine the dose to the patient's skin. "

ND NMED Event # ND210001


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.

EN Revision Imported Date: 3/30/2021

EN Revision Text: NON-AGREEMENT STATE REPORT LOST SOURCES IN TRANSIT

The following is a summary of a report received via phone:

On February 25, 2021, the licensee did not receive a shipment of three Cs-137 Brachytherapy sources with an aggregate quantity of 42.9 mCi (activities: 8.8 mCi, 8.7 mCi, and 25.4 mCi). The licensee reached out to the common carrier, who stated that it was still at their Memphis, TN distribution center and delayed due to the ice storm. The licensee has contacted the common carrier a number of times, with the last one taking place on March 18, 2021. The common carrier states they are still looking for the shipment package.

* * * UPDATE ON MARCH 29, 2021 AT 1908 EDT FROM TOM CLAWSON TO BRIAN P. SMITH * * *

The following update is a summary of a report received via phone:

On March 29, 2021, the licensee notified the Headquarters Operations Officer that the common carrier had located the licensee's sources that had been lost and shipped them back to the licensee. The licensee has receipted the sources back into their inventory. The common carrier recovered the lost sources on March 23, 2021.

Notified NMSS Events Notification (email), R4DO (Alexander), ILTAB (email), and R1DO (Janda).

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 - STUCK SHUTTER

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

"On March 22, 2021, the Agency was notified by the licensee's radiation safety officer (RSO) that earlier that day the shutter on a Berthold LD 8010 containing a 20 millicurie cesium-137 (original activity) source had failed to close. The gauge is installed on an inline section of pipe used in well fracking. The RSO stated that the roll pin for the shutter had failed and the operating arm would not rotate the shutter. The gauge was removed from the pipe and the operator was able to close the shutter. The RSO stated no overexposures occurred due to the event. The RSO stated a radiation survey of the gauge indicated dose rates were normal. The gauge was secured in a trailer on-site. The RSO stated the manufacturer was contacted and gauge will be packaged in a type 'A' container and sent to the manufacturer for repair. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 9832