Event Notification Report for March 18, 2024

AGREEMENT REPORT - STOLEN MOISTURE DENSITY GAUGE

The following information was provided by Alabama Radiation Control via email:

"The licensee's radiation safety officer (RSO) called Alabama Radiation Control at approximately 1549 CDT on Monday, 3/18/2024, to advise that one of their technicians had lost [reported stolen] a portable moisture density gauge at approximately 1445, around Bon Secour, AL.

"The RSO stated that the technician realized that the gauge was missing upon arrival at the licensee's location. The licensee received information that a member of the public (driving a gray F-150) stopped and retrieved the gauge.

"The licensee will notify local law enforcement, pawn shops, and advise local media about this matter. The licensee stated that a reward will be offered for the gauge's return. The RSO indicated that the source rod and transportation box were both locked.

"The gauge's (CPN MC-3) serial number is M39058845 with 10 millicuries of cesium-137 assayed March 1,1989, and 50 millicuries of americium-241/Beryllium assayed April 2, 1989."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

Alabama Radiation Control verified that the gauge was stolen from an unsecured truck bed. Also, they indicated that they will follow-up to verify that local law enforcement, pawn shops, and local media were notified.

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: 4/5/2024

EN Revision Text: AGREEMENT STATE REPORT - DOSE TO UNPLANNED SITE

The following was received from the Iowa Health and Human Services (HHS) via email:

"On 3/19/2024, MercyOne Des Moines Medical Center reported an equipment failure involving a Best Vascular Inc. A1000 series intravascular brachytherapy device, and a 2.16 Gbq (58.4 mCi) strontium-90 source that occurred on 3/18/2024.

"The initial attempt to send the source train failed to reach the dwell position and stopped short of the treatment area by about 30 millimeters. After the authorized user's (AU) attempts to try and increase pressure to send the sources further to the treatment area failed, the licensee decided to return the source to the device. There was a small delay in the source returning, because there was a slight bend in the catheter, and it seemed that was impeding the water pressure to push the source back. The licensee straightened the catheter a little bit, and when they did the source train returned to the device. At that point, the licensee disconnected and reconnected the catheter to try again and the source train again stopped in the same exact place. The licensee returned the source immediately.

"In total the source was in the incorrect position for approximately 30 seconds. The source was at the same position about 30 millimeters proximal to the treatment area.

"The AU picked up the radiopaque marker set to put back in and see if they could see how far it would go in on fluoroscopic imaging. When the AU picked up the radiopaque marker set, he noticed that there was a very strong kink (almost 90-degree bend) in the radiopaque marker set. Instead of putting the source radiopaque marker set back in, the licensee decided to pull the entire catheter and place a new beta-cath catheter in the patient. While testing the new radiopaque marker set (pulled them out, push them back in) the AU realized that when he did it on the other radiopaque marker set, he had felt a click at some point.

"The licensee's hypothesis is that, when the AU felt the click, the radiopaque marker set bent and there is a potential that when it bent, there was damage to the catheter itself, and it would not allow the source train to go past that position where the kink happened. With the new catheter in place, the AU connected the device and sent the source train out to the treatment position without issue. The licensee continued to treat for the prescribed treatment time.

"Preliminary information: It is estimated that the source train sat for approximately 30 seconds in the wrong location. The dose delivered to that area about 30 millimeter proximal to the treatment site is 0.0632 Gy/s times 30 s equals 1.896 Gy, which is greater than the limits described in 10 CFR 35.3045(a)(1)(iii) reports and notification of a medical event.

"Iowa HHS will do a reactive inspection on 3/20/2024 and will update this event as more details are confirmed."

* * * RETRACTION ON 4/4/24 AT 1301 EDT FROM STUART JORDAN TO TENISHA MEADOWS * * *

The following was received from the Iowa Health and Human Services (HHS) via email:

"Iowa HHS performed a reactive inspection on 3/20/2024 to confirm the facts and dose information. During this inspection, it was determined that the source train stopped in the aorta (30 mm vessel) in which the licensee's initial dose calculations was to a 2 mm vessel. Due to the characteristics of the strontium-90 beta emitter, there is a significant drop off in dose to the tissue with increased distance (3.75 mm goes below the 50 rem threshold). The catheter was not resting against the aorta wall when it had stopped for 20-30 seconds and the actual dose to the tissue was determined to be 5.25 rads [0.0525 Gy], which is approximately 10 percent of the reportable medical event threshold as described in 10 CFR 35.3045. Additionally, the reporting requirements described in 10 CFR 30.50(b)(2) also were not met. Specifically, the day of the incident the licensee used a new catheter and successfully treated without incident so there was redundant equipment available and operable to perform the required safety function.

"The licensee has sent the partially failed catheter to the vendor for an evaluation."

Notified R3DO (Edwards) and NMSS Events Notification via email.

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.

LOST NICKEL-63 SOURCES

The following is a summary of information received from the licensee via phone:

Licensee discovered three electron capture detectors (ECD) were missing on 03/18/2024. Each ECD contained 15 millicuries of nickel-63 (45 millicuries total). The last known accountability of these ECDs occurred at a leak test performed in 08/25/2020. The licensee suspects the ECDs may have been disposed of improperly.

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