Event Notification Report for June 22, 2023

EN Revision Imported Date: 6/22/2023

EN Revision Text: AGREEMENT STATE - LOST BRACHYTHERAPY SOURCE
The following was received by email from the South Carolina Department of Health and Environmental Control (The Department):

"The Department was notified on 05/09/23, that that one (1) Iodine-125 manual brachytherapy sealed source was lost or missing. The sealed source is a Bard Brachytherapy, Inc. Model STM 1251 with an activity of 0.34 mCi (12.58 MBq). The licensee reported that during a prostate seed implant procedure that occurred on 04/21/23, a single seed was possibly lost and remains unaccounted for. The licensee reported that during the procedure, an incorrectly configured strand was identified in the QuickLink device. This strand was ejected into the transfer device then pushed out into the sterile shielded shipping container so that the loose seeds could be counted. When assessing the seeds in the container, it was observed that one of the two I-125 seeds in this strand was missing. The medical physicists used a Geiger-Mueller counter to immediately survey the sterile cart and surrounding areas. The cart, floor, physician hands, nurse hands, and scrubs were all surveyed and no exposure was detected above background. Several other area surveys were also performed after the procedure was completed. The manual brachytherapy sealed source could not be accounted for.

"Department inspectors were dispatched to the facility on 05/17/23, and were unable to locate the missing sealed source. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

SC internal ID number is: SC230011

* * * UPDATE ON 6/21/2023 AT 0959 EDT FROM ADAM GAUSE TO BRIAN LIN * * *

The following was received by email from the South Carolina Department of Health and Environmental Control (The Department):

"A 30-day written report was submitted to the Department on 05/15/23 and a revised 30-day written report was submitted to the Department on 05/17/23. The licensee reported no exposure above background to individuals. The lot number of the manual brachytherapy sealed sources involved in the procedure is BBHQ0080, last leak tested 03/21/23. The licensee has also revised and adopted, or plan to adopt new procedures related to manual brachytherapy implant procedures. This event is considered closed."

Notified R1DO (Eve), ILTAB, and NMSS Notifications via email.

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

NON-AGREEMENT STATE - SURFACE CONTAMINATION ON OUTSIDE OF PACKAGE

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

On 6/14/23 around 0700 EDT, the licensee received three packages containing F-18 sources. Swipe readings on the packages revealed 42333 counts per minute (cpm), 12857 cpm, and 267 cpm. The packages had slightly elevated radiation readings. The radiation safety officer (RSO) and supplier were notified. There was no contamination found inside of the packaging, and the F-18 doses were double sealed without damage. Swipe readings were taken along the delivery path, but no spread of contamination to public spaces was detected. The affected packages were placed in a radiation storage area pending disposal.

AGREEMENT STATE REPORT - LOST/ABANDONED SOURCE

The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:

"On March 2, 2023, staff with the Illinois Emergency Management Agency and Office of Homeland Security responded to a load of scrap metal that tripped portal monitors in Indiana and was returned under DOT SP-IN-IL-23-001.The load of scrap originated at B.L. Duke in Forest View, IL. Within that load, a small unidentified radium-226 source was identified. It was estimated to contain approximately 150 microcuries of activity. On June 14, 2023, the licensing division learned of the recovery and began an investigation into the applicability of reporting requirements. There are no discernable markings or serial/model numbers. Activity estimates (based on dose rate) would place the source at approximately 150 microcuries. Aside from this source having significantly less activity, this appears to be a Ra-226 radiography source from the early 30's/40's. As this source does not appear to be exempt, it is likely byproduct material as a discrete source of radium and subject to specific licensure. Therefore, it is being reported as a lost/missing source. The source has been placed into the Agency's orphan source collection program and will be disposed of as low level radioactive waste."
Illinois report number: IL230015

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 - STUCK SHUTTER

The following information was provided by the Georgia Department of Natural Resources (the State) via email:

"On June 12, 2023, [the licensee] notified the State that they had discovered a stuck shutter on one of their fixed gauges [Ohmart Corp 4/2000 containing 100 mCi of Cs-137] that morning. The [licensee] had a service vendor repairing the handle of the gauge, and when they went to shut the shutter it wouldn't shut. They attempted to lubricate the shutter to get it to move, but it still would not close. It was determined that the issue will not cause undue exposure or risk to personnel. The vendor is sourcing the parts required for repair. As soon as the part is delivered, they will return to the site and replace the mechanism. Until then, the gauge will remain on the pipe with a notice attached to it, informing personnel of the issue to not interact with the gauge."

Georgia Incident Number: 66

AGREEMENT STATE REPORT - DOSE MISADMINISTRATION

The following information was provided by the Washington State Office of Radiation Protection via email:

"On 6/14/2023, a dose misadministration occurred during high dose rate brachytherapy at the Sacred Heart (SH) Radiotherapy Department. The authorized user (AU) intended for 15 Gy to be delivered in three [separate] 5 Gy fractions, but it was planned and delivered in a single 15 Gy treatment. The incident was discovered around 1630 [PDT] the same day. The AU has informed the patient and the referring physician.

"The SH medical physicist noted that 13 Gy in a single fraction is an effective treatment for the patient's condition (keloids on and around both ears). The 15 Gy was delivered to the keloid surface, and skin tolerance in a single fraction is greater than 25 Gy.

"Follow up with the patient will be perform in the next few days and ongoing. No other exposure to staff is reported."

WA incident number: WA-23-009

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.

AGREEMENT STATE REPORT - STUCK SHUTTERS

The following information was provided by the Texas Department of Health Services (the Agency) via email:

"On June 15, 2023, the Agency was notified by the licensee that during routine shutter checks, the shutters on two Berthold model LB7442 nuclear gauges were stuck in the open position. The gauges both contain a 20 millicurie (original activity) cesium - 137 source. Open is the normal operating position of the gauges. There is no risk of additional radiation exposure to members of the general public or radiation workers due to this failure. The investigation into this event is ongoing. Additional information will be provided as it is received in accordance with SA-300."

TX incident number: I-10026