Report missing radioactive material promptly

One of the best ways to thwart any attempt at stealing nuclear materials from your facility is to take seriously any report of missing material, says Fred Roll, president of the International Association for Healthcare Security and Safety in Glendale Heights, IL. You should have a policy of responding quickly and vigorously to any discrepancy in inventory or chain-of-custody records.

"Never assume it’s just a paperwork problem and will get sorted out in due time," he says. "When the consequences are this big, you can not afford to hope nothing is wrong and take your time investigating it. Investigate it to the hilt."

Missing radioactive materials must be reported to the Nuclear Regulatory Commission (NRC), which oversees security and safe handling in health care and other settings. Publicly available reports to the NRC indicate that health care providers often react to the loss of radioactive material by assuming a clerical error, which is sometimes the case. But Roll says the current threat of terrorism requires a lower threshold for alarm.

The NRC incident reports also give a glimpse into how easily radioactive materials can be lost. Roll says losing material is a more serious issue these days because, if your policies and procedures are not tight enough to prevent the accidental loss of the materials, you may never know whether any fell into the wrong hands.

Consider this report to the NRC of an incident at Fox Chase Cancer Center in Philadelphia on March 15, 2002:

"This is to inform you of an incident that occurred at our facility involving a recent shipment of 250 microcuries of phosphorous-32 [P-32] deoxyguanosine 5' triphosphate. . . . The package was delivered to the recipient lab, and the blue plastic container was placed in a freezer that was locked for storage of the material. On March 11, 2002, when the freezer was unlocked and the blue container was removed for use, there was no vial of P-32 inside. The lab worker immediately reported the situation to her Principal Investigator. Initially, the assumption was simply that the facility was shortchanged a vial, and indeed, that is our conclusion after investigation of the incident. . . . It was determined that the initial recipient did not follow the facility’s procedure for opening packages of radioactive material and failed to monitor the surface of the package or look inside and verify the contents."

High-tech keypad didn’t work

NRC reports also demonstrate that high-tech security is no good if it doesn’t actually work as intended. The NRC regularly inspects facilities for nuclear security and issues fines for violations. Wilcox Memorial Hospital in Lihue, HI, was fined $3,000 for a violation identified during an inspection on March 1, 2002.

The NRC described the violation this way: "The licensee failed to control and maintain constant surveillance of licensed material in a controlled or unrestricted area and not in storage. Specifically, on March 1, 2002, the licensee’s hot lab facility controlled area, containing curie quantities of molybdenum-99 contained in molybdenum-99/technetium-99m generators and other radiopharmaceuticals, was left unsecured and unattended. The door to the hot lab was shut and had an electronic keypad-type locking mechanism installed; however, it was determined that the lock did not function as designed, resulting in the door being unlocked."

In another incident March 14, 2001, the NRC fined I. Gonzalez Martinez Oncology in Hato Rey, Puerto Rico, $7,500 for an incident with a brachytherapy implant containing 97 millicuries of cesium-137. The implant was removed from a patient and then misplaced, exposing an employee to radioactivity for some time, and then found in a trash can in the alley behind the office 19 hours after it was lost.

An incident at Howard University Hospital in Washington, DC, on April 4, 2002, caused the NRC to levy a $3,000 fine. During a patient’s treatment for a tumor, one of 11 ribbons containing iridium-192 seeds was lost. The hospital never determined how the ribbon was lost but surmised that it must have been flushed down the sewer system because no traces were found in the laundry.