Event Notification Report for July 16, 2024

AGREEMENT STATE REPORT - LOST I-125 SEED

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

"The Department received notification from the licensee of a lost I-125 seed used for localization. A patient was implanted with (1) approximately 0.150 mCi I-125 seed on July 15, 2024. The patient returned to the hospital on July 16, 2024, to have the tissue, including the seed, removed. When the surgeon attempted to locate the seed, they were unable to detect it. The operating room and patient were surveyed but the seed was not located. The Department has requested additional information and continues to investigate the event.

"Additional information will be provided as it is received in accordance with SA-300."

Arizona Incident Number: 24-009

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 - FOUND SOURCE

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

"On 7/16/2024, the Agency was notified that the licensee found a box with seven calibration rod sources stored in the previous radiation safety officer's desk. The licensee had previously been cited for poor source accountability. The replacement of the radiation safety officer (RSO) and the use of a consultant were implemented as corrective actions. Locating and reporting these sources is a result of those efforts. The New England Nuclear gamma reference rod source set (Catalog No. NES-100T) contains a Co-57, Co-60, Cd-109, Ba-133, Cs-137, Mn-54, and Na-22 source - each with a nominal activity of 7 microcuries. While the sources were labeled as exempt when distributed in 1977, the Co-60 and Cd-109 sources appear to no longer be exempt under current regulations (10 CFR 30.71 Schedule B), nor does any exemption exist that grandfathers these sources. Wipe tests were performed and indicated no leakage.

"In accordance with SA-300, section 5.6.2, 'found sources' are to be reported when they exceed 10 times the value specified in Appendix C to 10 CFR Part 20. The Cd-109 source contained 12.9 microcuries when assayed 9/6/77, so, it remains reportable. The sources were placed on the licensee's sealed source inventory. Corrective action is adequate, and this matter is now considered closed."

IL Event Number: IL240016

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