Event Notification Report for January 12, 2022

EN Revision Imported Date: 1/12/2022

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO INCORRECT TREATMENT AREA

The following was received from the Florida Bureau of Radiation Control (the Bureau) via email:

"On Friday, December 31, 2021, the Bureau was contacted by [the Radiation Safety Officer] to report a medical event at Horizon Medical Services that occurred on December 15, 2021. The medical event was the [high dose rate therapy] treatment of the incorrect hand using iridium-192 to a single dose fraction of 250 cGy [(250 rem)] to a depth of 3mm below the skin surface."

The licensee's report to the Bureau stated, "Remedial action included an immediate in-service discussion of this event with the entire clinical staff to verify the correct anatomical treatment site regarding all patient prescriptions. The patient has been informed of this medical event."

Florida Incident No.: FL 21-152

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: 1/12/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCE

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

"On January 4, 2022, the licensee notified the Agency that on January 3, 2022, one of its technicians lost a Humboldt model 5001EZ moisture/density gauge (SN: 9313), containing a 40 millicurie americium-241 source and a 10 millicurie cesium-137 source, at a temporary job site. The technician reported that he had placed the gauge, without the source insertion rod locked, into the transport case and then into the transport box in the bed of the pickup but did not lock the box since he was going across the job site. He traversed bumpy ground to the next testing area and when he went to get the gauge he found it was not in the box. He returned to the previous test area and found the transport case but not the gauge. The job site was thoroughly searched and other workers at the job site were questioned.

"The search resumed on January 4, 2022. In addition, onsite workers are being contacted and a reward is being offered. Local police have been notified. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: 9606

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