Event Notification Report for December 04, 2023

AGREEMENT STATE REPORT - PATIENT RECEIVED LESS THAN PRESCRIBED DOSE

The following report was received via email from the Alabama Department of Public Health, Office of Radiation Control (the Office):

"The Office was notified of the medical event during a licensee inspection between February 6 to February 8, 2024. The licensee reported that during a patient's 3rd treatment on 12/4/2023, dwell positions in part of the high dose rate (HDR) applicator (2 ovoids) were successfully completed. Dwell positions in another part of the applicator (the tandem) were interrupted due to an obstruction. After repeated checks and attempts, dwell positions in the tandem could not be completed. The patient received 100 cGy of the intended 600 cGy for the third treatment on 12/4/2023.

"The licensee examined the applicator, and determined that there appeared to be microfractures in the area of the tandem. The licensee has replaced this applicator, and developed precautionary safety procedures to avoid this matter in the future. The licensee noted that the matter appears to be related to the autoclaving process for applicators. The licensee also revised the patient's treatment course, and the patient was successfully treated during 4th and 5th fractions.

"The licensee used an Elekta Flexitron serial number: FT00306, with an Alpha-Omega model 136147 source, serial number: D85F-2336, 11.86 Ci of Ir-192 on 11/17/2023."

Alabama Incident Number: Pending

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 - LOST STATIC ELIMINATOR

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

"On November 1, 2024, the Department was notified by the licensee that it discovered it had a missing general licensed device during an inventory verification exercise. The device, which is a P2042 static eliminator, has not been accounted for as of December 4, 2023. This discovery was made by the EHS technician. The technician conducted an internal exercise to verify the inventory of these devices and discovered that there was a missing device. The technician contacted the device manufacturer who advised the licensee to contact the Department. The device contains a 5 millicurie (original activity - around October 2023) polonium-210 sealed source. The licensee stated the device did not pose a risk of exposure to any individual. The licensee searched for the device, but was unable to locate it. The licensee has since made several administrative controls to avoid such a situation in future."

Texas Incident Number: 10139
Texas NMED Number: TX240040

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