Event Notification Report for December 23, 2021

EN Revision Imported Date: 12/23/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED

The following information was received from the state of Minnesota via email:

"A 298 æCi I-125 localization seed was lost in the licensee's pathology department after removal. The seed was confirmed missing on October 24, 2021 when paperwork and inventories confirmed it was not returned to the Nuclear Medicine Department."

MN incident no.: MN210008

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

EN Revision Imported Date: 12/23/2021

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE

The following was received from the Tennessee Division of Radiological Health via email:

"A Troxler model 3440 (SN 21556) was run over by a dump truck at a local construction site. Source is in the shielded position within the unit. Gauge is cordoned off from staff. However, the gauge is not operational.

"Corrective actions will be updated with a report within 30 days."

The gauge contains a 40 mCi Am:Be-241 and a 8 mCi Cs-137 source.

State Event Report ID Number: TN-21-116

EN Revision Imported Date: 12/23/2021

EN Revision Text: LOST SURVEY INSTRUMENT

The following information was received from the Radiation Safety Officer (RSO) at the Environmental Protection Agency (EPA), Region 8 via telephone:

On 12/13/21, the RSO received notification reporting a missing shipment containing a Ludlum Model 192 survey instrument. The survey instrument contains a 1 microCi Cs-137 source and was scheduled for calibration at a facility in Sweetwater, TX. The common carrier reported that the incorrect shipping label was placed on the survey instrument's package and sent to an unknown location. The common carrier is conducting an investigation to determine the location of the survey meter. The last location of the survey meter was in Hutchins, TX.

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

EN Revision Imported Date: 12/23/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED

The following was received from the Tennessee Division of Radiological Health via email:

"During the removal of I-125 seeds from a patient, only 22 of 23 seeds were recovered. No survey readings above background were discovered in the operating room. It was concluded that the seed was not present in the patient upon operating room entry. Exam rooms visited by the patient were checked and showed no readings above background levels. The seed is thought to have been lost during implant with surgical drape on 12/7/21. The seed information is as follows:

"Manufacturer: BEST
"Model: 2301
"Isotope: I-125
"Activity: 1.6 mCi

"Corrective actions will be updated with a report within 30 days."

State Event Report ID Number: TN-21-117

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

EN Revision Imported Date: 12/23/2021

EN Revision Text: LEAKING SOURCE FROM AIRCRAFT RADIUM DIAL

The following is a summary from a phone call with the licensee:

At 1438 MST on December 15, 2021, base personnel at Kirtland Air Force Base identified a potentially leaking radium-226 aircraft dial. The activity contained within the dial and the leak rate were not known at the time of the call. The storage area for the dial has been locked and flagged pending further investigation. Dosimetry for base personnel did not identify any unexpected exposure. The licensee has contacted NRC Regional Inspectors.

EN Revision Imported Date: 12/23/2021

EN Revision Text: NON-AGREEMENT STATE - LOST Co-57 MARKER SOURCE

The following is a summary of a phone call with Lester E. Cox Medical Center:

On November 23, 2021, the licensee was performing a radiography procedure on a patient's lymph node. The procedure involved the use of a Co-57 marker rod source, approximately 13.1 microCi. During the procedure the shielding cap was removed, reference mark was made, the cap was replaced, and the rod was placed back onto a medical cart. At some point following the procedure the licensee recognized that the source was missing. A search of the lab, linen area, and trash was conducted and did not identify the missing source.

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

EN Revision Imported Date: 12/23/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED

The following information was received from the state of Minnesota via email:

"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.

"Fairview Southdale Hospital (FSH) reported a missing 8.36 MBq (226 microCi) I-125 localization seed (IsoAid model IAI-125A). The seed was discovered missing on 8/19/2021. Two I-125 seeds were placed in a patient for localization of non-palpable lesions. Both seeds were removed in the operating room, which was confirmed by imaging. The tissue was sealed in a container in the operating room and taken to Pathology. During processing of the tissue, Pathology could only locate one of the seeds. FSH surveyed the operating room and Pathology. The seed was not located. The operating room had been cleaned prior to the survey. It is not known if the seed went missing in the operating room or Pathology. FSH planned to modify their procedure to place the specimen in a Zip-Lock bag before being imaged in the operating room and kept in the bag when transported to Pathology. Also, Pathology will analyze the specimen in a timely fashion so if a seed does go missing, it will have less time to be moved around."

Minnesota event number: 210006

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

EN Revision Imported Date: 12/23/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED

The following information was received from the state of Minnesota via email:

"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.

"Mayo Clinic reported the loss of an I-125 localization seed (Best Medical model 2301, lot #49827) that contained an activity of 9.03 MBq (244 microCi). A lesion and the seed were removed from a patient on 3/17/2020. After the lesion was removed from the patient, the surgeon confirmed that the seed was within the specimen with a survey meter. However, the surgeon did not perform a radiograph of the specimen, nor did he inform pathology per procedure that there was a seed to be removed. The seed was noted to be missing by a nuclear medicine technologist on 3/19/2020, which prompted an investigation. All of the remaining lesion tissue was recovered and surveyed, along with the entire pathology laboratory, on 3/20/2020. Mayo Clinic was unable to locate the seed following investigation and determined it was lost. They assumed that the seed was either washed down the sink in the pathology laboratory or incinerated as medical waste. The cause of the incident was concluded to be inadequate training. Corrective actions included developing a new process for selecting a surgeon and radiologist to ensure that qualified personnel are following procedures."

Minnesota event number: 200003

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

EN Revision Imported Date: 12/23/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED

The following information was received from the state of Minnesota via email:

"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.

"Fairview Southdale Hospital (FSH) reported the loss of two I-125 seeds (IsoAid model IAI-125A) used for localization of non-palpable lesions. Each seed contained an activity of 11.1 MBq (300 microCi). The seeds were discovered to be missing from their decay-in-storage area while placing a new seed in storage on 12/5/2019. FSH staff decided to count the seeds that were in the storage pig. There should have been 20 seeds, but only 18 seeds were counted. FSH conducted an investigation and determined that the two seeds were lost. Corrective actions included conducting daily radiation surveys of all areas of the breast center hot laboratory."

Minnesota event number: 200001

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

EN Revision Imported Date: 12/23/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED

The following information was received from the state of Minnesota via email:

"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.

"Abbott Northwestern Hospital (ANH) reported the loss of a 6.845 MBq (185 microCi) I-125 localization seed (Best Medical International model 2301, lot #48287) from the ANW Piper Breast Center on 7/26/2019. A tissue specimen containing the seed was removed from a patient and transported to pathology. The pathology assistant removed the seed from the specimen and placed it adjacent to the specimen in the workspace. After the pathologist and surgeon examined the specimen, the assistant noticed that the seed was missing. ANH conducted radiation surveys of the surrounding area (staff clothing, shoes, and adjacent hallways), but did not locate the seed. ANH believes that while the pathologist and surgeon were examining the specimen, the seed was bumped into the sink and washed down the drain. Corrective actions included procedure modification and providing additional training to personnel. During subsequent procedures, pathology staff will place the seed into a lead container before the pathologist and surgeon examine the specimen."

Minnesota event number: 190004

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

EN Revision Imported Date: 12/23/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST STATIC ELIMINATOR

The following information was received from the state of Minnesota via email:

"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.

"New Flyer reported the loss of a static elimination device (NRD model P-2021, serial #A2KY665) that contained a 370 MBq (10 milliCi) Po-210 source. While New Flyer was preparing to replace their devices, they discovered that one device was missing. They performed an investigation, which included searching the painters' lockers and totes, but were unable to find the device. The manufacturer was notified. The cause of the event was determined to be lack of procedure. Corrective actions included connecting static elimination devices to dedicated air lines to ensure they will not be misplaced."

Minnesota event number: 180001

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

EN Revision Imported Date: 12/23/2021

EN Revision Text: AGREEMENT STATE REPORT - GAUGE SHUTTER STUCK OPEN

The following information was received from the state of Minnesota via email:

"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.

"Certainteed Corporation reported that the shutter on a fixed nuclear gauge (Thermo EGS model SCL-1C, serial #UX458) failed to close on 5/11/2017. The gauge contained a 3.7 GBq (100 milliCi) Sr-90 source (Eckert & Ziegler model SIF.D1). The area within 15 feet of the gauge was cordoned off. Certainteed contacted the manufacturer and arrangements were made for Thermo EGS to inspect and service the gauge on 5/12/2017. The cause of the event was determined to be a broken pin on the mechanical plate that controls the on-off indicator light. The pin was repaired and the shutter mechanism was tested and performed properly. The Minnesota Department of Health conducted an onsite visit."

Minnesota event number: 170004

EN Revision Imported Date: 12/23/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST LICENSED DEVICE

The following information was received from the state of Kansas via email:

"An anti-static device has gone missing from the Western Industries Plastic Products facility. The device was leased from NRD, LLC (Lease number 75780, model number P-2031-1000, and serial number A2MJ492). The Safety Manager reported it to NRD, which responded on 12/15/21 to instruct them to contact the state.

"Routinely, the device is attached to a nozzle at one end and a gauge at the other, which connects to a quick-release hose. At the end of the day, it is disconnected by the quick-release connector and placed in the unlocked bottom drawer of a filing cabinet at the end of the assembly line. In the morning, it is reconnected. The assembly line is located in the warehouse portion of the facility, which is used to mold large pieces of plastic for a variety of companies. The device / air nozzle is used to blow out debris created from cutting holes in these large parts.

"At the end of first shift on 12/8/21 at 1600 [CST], the device was put in the bottom drawer of a filing cabinet (unlocked) at the end of assembly line. This was confirmed by interview with the assembly line worker who placed it there. On 12/9/21 at 0800 [CST] a worker at the start of shift went to retrieve it, but the device could not be located. A complete search was made of the facility by the Safety Manager and others from all shifts, searching the entire facility including all cabinets in the work area, the shipping offices, and the docks.

"The facility has not given up looking for the device, but if it is considered lost, they have not decided if they will continue with another radioactive device. If they do, they have stated their intention to use a sign-in/sign-out system and padlock when the device is not in use. "

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