Event Notification Report for April 15, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/14/2024 - 04/15/2024
Non-Agreement State
Event Number: 57095
Rep Org: George Washington Hospital
Licensee: George Washington Hospital
Region: 1
City: District of Columbia State: DC
County:
License #: 0830607-01
Agreement: N
Docket:
NRC Notified By: Sarah Mills
HQ OPS Officer: Thomas Herrity
Licensee: George Washington Hospital
Region: 1
City: District of Columbia State: DC
County:
License #: 0830607-01
Agreement: N
Docket:
NRC Notified By: Sarah Mills
HQ OPS Officer: Thomas Herrity
Notification Date: 04/30/2024
Notification Time: 16:43 [ET]
Event Date: 04/15/2024
Event Time: 13:00 [EDT]
Last Update Date: 04/30/2024
Notification Time: 16:43 [ET]
Event Date: 04/15/2024
Event Time: 13:00 [EDT]
Last Update Date: 04/30/2024
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
Person (Organization):
Eve, Elise (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Eve, Elise (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
LOST IODINE-125 IMPLANT SEED
The following is a synopsis of information provided by the licensee via phone call:
On 4/15/24, a 145 microcurie iodine -125 implant seed was lost. The seed was one of four seeds to be implanted for mammography. During the exam, it was discovered that only three seeds were implanted. Licensee staff verified that the seed was not implanted in the patient. A thorough survey of the room, linens, and trash was performed and did not yield the seed. Licensee staff can not verify that the seed was present in the needle prior to the procedure.
The patient and the prescribing physician were made aware of the missing seed. No negative effect on the patient is expected.
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
The following is a synopsis of information provided by the licensee via phone call:
On 4/15/24, a 145 microcurie iodine -125 implant seed was lost. The seed was one of four seeds to be implanted for mammography. During the exam, it was discovered that only three seeds were implanted. Licensee staff verified that the seed was not implanted in the patient. A thorough survey of the room, linens, and trash was performed and did not yield the seed. Licensee staff can not verify that the seed was present in the needle prior to the procedure.
The patient and the prescribing physician were made aware of the missing seed. No negative effect on the patient is expected.
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
Event Number: 57106
Rep Org: SC Dept of Health & Env Control
Licensee: Carolina Canners, Inc.
Region: 1
City: Cheraw State: SC
County:
License #: GL-0084
Agreement: Y
Docket:
NRC Notified By: Korina Koci
HQ OPS Officer: Ian Howard
Licensee: Carolina Canners, Inc.
Region: 1
City: Cheraw State: SC
County:
License #: GL-0084
Agreement: Y
Docket:
NRC Notified By: Korina Koci
HQ OPS Officer: Ian Howard
Notification Date: 05/03/2024
Notification Time: 17:21 [ET]
Event Date: 04/15/2024
Event Time: 00:00 [EDT]
Last Update Date: 05/28/2024
Notification Time: 17:21 [ET]
Event Date: 04/15/2024
Event Time: 00:00 [EDT]
Last Update Date: 05/28/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Eve, Elise (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Eve, Elise (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 5/29/2024
EN Revision Text: AGREEMENT STATE REPORT - LOST NUCLEAR GAUGES
The following information was provided by the South Carolina Department of Health and Environmental Control (the Department) via phone and email:
"The Department was notified via telephone on 5/3/2024, that four fixed gauging devices were unaccounted for by the general licensee. The general licensee is reporting that four Industrial Dynamics fixed gauging devices (model number FT 50) containing 100 mCi (3.7 GBq) of americium-241 each, for a total of 400 mCi (14.8 GBq), were sent to a recycling facility on 3/8/2024. The serial numbers for the four fixed gauging devices were as follows: 112531, 112532, 112533, 112534. The general licensee is reporting no immediate health and safety concerns, or ongoing emergencies. Department inspectors will be dispatched. This event is still under investigation by the Department. No internal event identification number has been assigned to this event."
* * * UPDATE ON 5/28/24 AT 0953 EDT FROM KORINA KOCI TO ADAM KOZIOL * * *
"Department inspectors were dispatched to the recycling facility on 05/08/24, but were unable to locate the missing fixed gauging devices. The general licensee submitted a 30-day written report on 05/24/24. This event is still under investigation by the South Carolina Department of Health and Environmental Control."
The internal event number is SC 240002
Notified R1DO (DeFrancisco) and NMSS Events (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
EN Revision Text: AGREEMENT STATE REPORT - LOST NUCLEAR GAUGES
The following information was provided by the South Carolina Department of Health and Environmental Control (the Department) via phone and email:
"The Department was notified via telephone on 5/3/2024, that four fixed gauging devices were unaccounted for by the general licensee. The general licensee is reporting that four Industrial Dynamics fixed gauging devices (model number FT 50) containing 100 mCi (3.7 GBq) of americium-241 each, for a total of 400 mCi (14.8 GBq), were sent to a recycling facility on 3/8/2024. The serial numbers for the four fixed gauging devices were as follows: 112531, 112532, 112533, 112534. The general licensee is reporting no immediate health and safety concerns, or ongoing emergencies. Department inspectors will be dispatched. This event is still under investigation by the Department. No internal event identification number has been assigned to this event."
* * * UPDATE ON 5/28/24 AT 0953 EDT FROM KORINA KOCI TO ADAM KOZIOL * * *
"Department inspectors were dispatched to the recycling facility on 05/08/24, but were unable to locate the missing fixed gauging devices. The general licensee submitted a 30-day written report on 05/24/24. This event is still under investigation by the South Carolina Department of Health and Environmental Control."
The internal event number is SC 240002
Notified R1DO (DeFrancisco) and NMSS Events (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