Notified R1DO (Arner), NMSS (Rivera-Capella) and NMSS Events Notification via email.Ī Medical Event may indicate potential problems in a medical facility's use of radioactive materials. The individual's readings were as follows: The dosimeters were immediately sent out for processing after the event and the actual readings were below the reportable limit. Initial dose estimates for the individuals who were present in the room while the HDR source was outside the HDR unit due to malfunction of the unit were conservatively estimated to be greater than the 5 rem reportable limit.
#Hdr projects 4 vs photomatirx update#
The following update is a summary of information received from the licensee via email: * * * UPDATE ON 04/21/23 AT 0930 EDT FROM KELLY STONEBERG TO KERBY SCALES * * * "No adverse effects anticipated to the patient from this event, and the shortfall in dose will be made up at a future date." "Staff were successful in returning source to a safe condition, and a manufacturer representative will be conducting an inspection of the device before further use. "Badge dosimetry was collected and sent for processing to confirm actual doses received. "Preliminary dose estimates received by personnel are as follows: "After several unsuccessful attempts to bring the source to the safe position, the applicator was removed from the patient, the patient was removed from the room, and the room was closed and sealed. As a result, the treatment was shutdown, and emergency procedures instituted. It then treated the left ring properly, but at the end of treatment it gave an error message, and the radiation monitors in the room and above the door indicated that the source did not return to the safe position. "The HDR unit functioned properly in treating the first section, the right ring. The total dose for the four treatments is 1,656 cGy which is 83 percent of prescribed. "Computed clinical dose to the patient was 156 cGy to the A points which is 31 percent of what was prescribed. The intended dose was 500 centi-Gray (cGy) to points called Right A and Left A, 2 cm up and 2 cm out from the cervical os. The applicator has three sections: right and left partial rings on either side of the cervical os, and a tandem inserted into the cervix. "At about 1000 EDT on 4/19/23 the licensee was performing an HDR treatment on a patient's cervix using a Nucletron B.V 136149A02 model Flexitron HDR remote after loader containing a 12 Ci Ir-192 source. The following information was provided by the licensee via email: STUCK SOURCE WITH POTENTIAL OVEREXPOSURE AND MEDICAL UNDERDOSE Notified R3DO (Orth), NMSS Events, and ILTAB The State of Arkansas has been notified." The other four shipments were sent to a hazardous waste vendor in Arkansas and incinerated. "On April 19, 2023, the Department became aware that of the eight referenced shipments inadvertently containing carbon-14, only four shipments were sent to a hazardous waste vendor in Nebraska. * * * UPDATE ON 4/20/23 AT 1250 EDT FROM MEGAN SHOBER TO ADAM KOZIOL * * * The Department performed a reactive inspection, and the investigation is ongoing." The licensee immediately contacted the recipient and determined that the waste had already been incinerated. The largest single shipment contained 1.19 millicuries of carbon-14.
In total the amount of carbon-14 that was improperly disposed of was 3.88 millicuries. The eight shipments occurred between July 26, 2019, and October 27, 2022. On February 23, 2023, the licensee discovered that eight shipments were sent to a hazardous waste vendor in Nebraska for disposal, and the waste inadvertently contained carbon-14 radiolabeled pharmaceutical samples used for research and development.
"On March 21, 2023, the licensee, PPD Development, LLC, reported a loss of control of radioactive material to the Department. The following information was provided by the Wisconsin Radiation Protection Section (the Department) via email: AGREEMENT STATE REPORT - LOSS OF CONTROL OF RADIOACTIVE MATERIALS
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