| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
07/20/2006 - 07/21/2006 ** EVENT NUMBERS ** |
 | General Information or Other | Event Number: 42707 | Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: ANNE ARUNDEL COUNTY MEDICAL CENTER
Region: 1
City: ANNAPOLIS State: MD
County: ANNE ARUNDEL
License #: MD-0300106
Agreement: Y
Docket:
NRC Notified By: RAY MANLEY
HQ OPS Officer: PETE SNYDER | Notification Date: 07/17/2006
Notification Time: 14:55 [ET]
Event Date: 07/03/2006
Event Time: [EDT]
Last Update Date: 07/18/2006 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
JOHN KINNEMAN (R1)
GREG MORELL (NMSS)
| Event Text AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION USING HIGH DOSE RATE AFTERLOADER
On 7/17/06 the State of Maryland received a report from the Anne Arundel Medical Center in Annapolis, Maryland of a potential medical misadministration using a high dose rate afterloader.
Approximately two to three weeks ago a patient was administered a dose using a Varian VariSource 200 HDR brachytherapy afterloader to treat a lung tumor. During the dose administration the catheter was determined to be about ten centimeters short of the planned location for the dose. Because of the mispositioning or the catheter, an unintended dose of less than 100 centigray was given to patient's vocal chord area. The lungs received a dose of 5 gray. The licensee notified the patient of the issue. A licensee physician examined the patient today and determined that there was no erythema and that there would be no adverse medical effects in the unintended dose area. The licensee reported that a human error not a device error resulted in the misadministration.
The State will be conducting follow-up investigations into this incident to include reviewing the licensee's determination of the cause, as well as, determining why the event was not reported until 2 to 3 weeks after it had occurred.
Typically a 10 curie Iridium-192 source is used in this type of instrument.
* * * UPDATE AT 1100 EDT ON 07/18/06 FROM RAY MANLEY TO S. SANDIN * * *
The patient did not receive a dose of 5 gray to the lungs as described above. This was the prescribed dose. Also, the information is preliminary pending completion of the follow-up investigation. Notified R1DO (Kinneman) and NMSS (Morell). |
| General Information or Other | Event Number: 42708 | Rep Org: ALABAMA RADIATION CONTROL
Licensee: OMI, INC
Region: 1
City: HUNTSVILLE State: AL
County:
License #: 1171
Agreement: Y
Docket:
NRC Notified By: DAVID TURBERVILLE
HQ OPS Officer: BILL HUFFMAN | Notification Date: 07/17/2006
Notification Time: 14:34 [ET]
Event Date: 07/17/2006
Event Time: [CDT]
Last Update Date: 07/17/2006 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
JOHN KINNEMAN (R1)
GREG MORELL (NMSS)
| Event Text ALABAMA AGREEMENT STATE REPORT OF FOUND MOISTURE DENSITY GAUGE
The State provided the following information via facsimile:
"On the morning of July 17, 2006, the Alabama Office of Radiation Control was contacted by Madison County Emergency Management Agency concerning a container found in the middle of a street in Huntsville, Alabama. The incident was originally reported by a passerby to the Huntsville Police Department. The Huntsville Police Department, Huntsville Fire and Rescue Department, and Huntsville HAZMAT unit responded to the call. Also, local news media was at the scene. The item was determined to be a CPN Model MC-3 moisture density gauge (Serial No. M350402559) containing 10 millicuries of Cesium-137 and 50 millicuries of Americium-241/Beryllium. An investigation found that the device was the property of OMI, Inc. of Huntsville, Alabama. OMI Inc. has an Alabama Radioactive Material License No. 1171 to possess and use the device. The licensee was notified by the Alabama Office of Radiation Control of the found gauge and they returned to the scene to pick it up. Preliminary findings indicate that the licensee failed to secure the device by two independent means in the back of the pickup truck and failed to properly block and brace the device during transport. It does not appear that the device suffered any significant damage but the licensee was advised to perform a leak test of the device before placing the unit back in service."
Alabama Event 06-36. |
| General Information or Other | Event Number: 42709 | Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: UNKNOWN
Region: 4
City: Venice State: LA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: BILL HUFFMAN | Notification Date: 07/17/2006
Notification Time: 15:31 [ET]
Event Date: 07/15/2006
Event Time: [CDT]
Last Update Date: 07/17/2006 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
VIVIAN CAMPBELL (R4)
GREG MORELL (NMSS)
| Event Text LOUISIANA AGREEMENT STATE REPORT OF RADIOACTIVE SOURCE FOUND AT OLD TEXACO SITE
The State provided the following information via facsimile:
"While performing NORM [naturally occurring radioactive material] remediation at an old Texaco site at the end of Hwy 23 in Venice, LA, a radioactive source was uncovered. Production Management Industries (PMI) was dipping out mud out of a canal when, the scoop of mud had a high reading. The scoop was set aside in a restricted area. It was thought to be NORM pipe until the survey meter used on NORM material pegged. They also noticed that the piece of metal giving off radiation was about two inches long. Then it was believed to be a sealed source. Mr. [Redacted] was called about the situation. Mr. [Redacted] told them to set it aside until he got there. Once Mr. [Redacted] was on site they took a survey of the source with a different survey meter. The reading at contact was 30 mR/hr. It was 100 microR/hr at 3 feet and 20 microR/hr at 10 feet. Mr. [Redacted] performed a wipe test on the source and it did not appear to be leaking. Mr. [Redacted] then put the source in a 5 gallon drum and put dry cement around the source. The reading at the drum after this was 1.9 mR/hr. He then put the drum in the generator room where it could be locked up and secure. American Radiation Services is going to pick up the source from Venice on July 17 for disposal. All the employees that were around the source are radiation workers and were wearing personnel monitoring. No excessive exposures are expected. No one picked up the source by hand."
Louisiana Report Number LA0600014 |
| General Information or Other | Event Number: 42710 | Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: PROFESSIONAL SERVICE INDUSTRIES INC
Region: 4
City: TACOMA State: WA
County:
License #: WN-IR021-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: BILL HUFFMAN | Notification Date: 07/17/2006
Notification Time: 16:43 [ET]
Event Date: 07/17/2006
Event Time: 04:00 [PDT]
Last Update Date: 07/17/2006 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
VIVIAN CAMPBELL (R4)
WILLIAM RULAND (NMSS)
ILTAB (E-MAIL) ()
CANADA (VIA FAX) ()
|
| This material event contains a "Less than Cat 3" level of radioactive material. | Event Text WASHINGTON AGREEMENT STATE REPORT OF STOLEN TROXLER GAUGE
The State provided the following information via email:
"The licensee reported that a Troxler portable moisture/density gauge model 3430, serial number 25598 was stolen between 4:00 a.m. and 6:00 a.m. today. The gauge was in a 1987 Toyota Camry when the car itself was stolen from the residence of an employee living in Renton, Washington. The gauge was in the trunk of the car at the time of the theft. The licensee reported that the truck was locked, the transport box was locked and the gauge was locked. The licensee did not have a required second outer level of security in place to keep an unauthorized individual from removing the locked box with the gauge. The licensee did not keep the gauge stored at the licensed storage location as required by license condition. The user retrieved the gauge Sunday night (July 16, 2006) from the licensed storage location located several miles north of his residence for use today at a temporary jobsite several miles south of his residence. The theft was reported to the Renton Police Department (police report #4626) and was assigned Case #06-7698. " Washington Event Report # WA-06-050
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. |
| Hospital | Event Number: 42716 | Rep Org: UNIVERSITY OF VIRGINIA MEDICAL CENT
Licensee: UNIVERSITY OF VIRGINIA MEDICAL CENT
Region: 1
City: CHARLOTTESVILLE State: VA
County:
License #: 45-00034-26
Agreement: N
Docket:
NRC Notified By: KATHRINE PERHAM
HQ OPS Officer: ARLON COSTA | Notification Date: 07/20/2006
Notification Time: 16:45 [ET]
Event Date: 07/11/2006
Event Time: [EDT]
Last Update Date: 07/20/2006 | Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(b) - PATIENT INTERVENTION DAMAGE
| Person (Organization):
JOHN KINNEMAN (R1)
LAWRENCE KOKAJKO (NMSS)
| Event Text MEDICAL EVENT INVOLVING SOURCE CAPSULE EGRESS FROM PATIENT
On 7/11/06, the licensee administered an I-131 source (54.6 millicuries) to an elderly female for Goiter treatment and subsequently released her. On 7/20/06, the patient went with her daughter to another medical center in West Virginia, and it was related to the staff that a capsule was under the patient's pillow. The staff requested and the capsule was brought to the center, which was confirmed to be the source intended for the patient's treatment at the University of Virginia Medical Center. The West Virginia medical center contacted the licensee and has possession of the source capsule in their hot lab. This incident is being monitored by the licensee who is continuing with an investigation. | |