Event Notification Report for March 22, 2023

LOST SOURCE

The following is a summary of information provided by the licensee via phone:

On February 24, 2023, the Radiation Safety Officer (RSO) noticed a missing source during an annual radioactive material audit. The missing radioactive source is a Nano Tritium sealed source from City Labs (Model: P100a, S/N: 1020140018) containing 94 mCi of H-3. The RSO notified the principle investigator to begin a search for the sealed source, however, the source could not be located. The RSO believes the missing radioactive source may have been confused with an identical non-radioactive battery during previous audits, and the length of time the source has been missing is unknown.

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 - PATIENT TREATMENT SUSPENDED PRIOR TO COMPLETION

The following information was provided by the New Jersey Department of Environmental Protection (DEP) via email:

"While receiving treatment with an Elekta Leksell Gamma Knife ICON unit, serial number 6135, the patient's treatment had to be suspended. During the administration of the treatment, after the conclusion of a prescribed shot, but before completion of the full treatment, the unit displayed an error that could not be resolved by licensee personnel and required a service technician. The treatment was consequently suspended. The service technician identified a worn sector drive as the cause of the malfunction. The dose administered versus the dose prescribed is still under discussion. The licensee will follow-up with a full report."

NJ Event Report ID number: NJ-23-0001
* * * UPDATE ON 3/16/23 AT 1513 EST FROM RICHARD PEROS TO BILL GOTT * * *
"Additional information has been obtained related to the initial notification provided on 3/15/23.
"The dose administered to the patient was only approximately 2.9 percent of the dose prescribed.
"The prescribed dose was 15 Gy.
"The unit malfunctioned after only 3 of the planned 13 shots was completed.
"14.5589 Gy still needed to be administered out of the 15 Gy when the malfunction occurred.
"This incident therefore does qualify as a medical event as per 10 CFR 35.3045(a)."
Notified R1DO (Bickett) and NMSS Events Notification.


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