Event Notification Report for September 15, 2009
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/14/2009 - 09/15/2009
General Information or Other
Event Number: 45355
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: GREENVILLE MEMORIAL HOSPITAL
Region: 1
City: GREENVILLE State: SC
County:
License #: 257
Agreement: Y
Docket:
NRC Notified By: MELINDA BRADSHAW
HQ OPS Officer: JOHN KNOKE
Licensee: GREENVILLE MEMORIAL HOSPITAL
Region: 1
City: GREENVILLE State: SC
County:
License #: 257
Agreement: Y
Docket:
NRC Notified By: MELINDA BRADSHAW
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/17/2009
Notification Time: 12:11 [ET]
Event Date: 09/15/2009
Event Time: 00:00 [EDT]
Last Update Date: 09/17/2009
Notification Time: 12:11 [ET]
Event Date: 09/15/2009
Event Time: 00:00 [EDT]
Last Update Date: 09/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DON JACKSON (R1DO)
ANGELA MCINTOSH (FSME)
DON JACKSON (R1DO)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE REPORT - PATIENT GIVEN WRONG DOSE
The following information was faxed in by the State:
"The South Carolina Department of Health and Environmental Control was notified on September 17, 2009, by the licensee, that a medical event occurred. A patient who was scheduled for a Yttrium-90 Microsphere therapy was given the wrong dose. The patient was scheduled for 25.38 millicuries but was administered 45.9 millicuries according to the initial report by the licensee.
"The event took place on the 15th and was verified by the licensee on the 17th of September. The referring physician has been notified as well as the patient. The licensee knew no additional details at this point. The licensee will provide additional information in a written report within 15 days. Updates to this event will be made through the NMED system as further information is received."
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
The following information was faxed in by the State:
"The South Carolina Department of Health and Environmental Control was notified on September 17, 2009, by the licensee, that a medical event occurred. A patient who was scheduled for a Yttrium-90 Microsphere therapy was given the wrong dose. The patient was scheduled for 25.38 millicuries but was administered 45.9 millicuries according to the initial report by the licensee.
"The event took place on the 15th and was verified by the licensee on the 17th of September. The referring physician has been notified as well as the patient. The licensee knew no additional details at this point. The licensee will provide additional information in a written report within 15 days. Updates to this event will be made through the NMED system as further information is received."
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
General Information or Other
Event Number: 45351
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: CAPITAL X-RAY
Region: 4
City: TULSA State: OK
County:
License #: OK-11114-02
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: JASON KOZAL
Licensee: CAPITAL X-RAY
Region: 4
City: TULSA State: OK
County:
License #: OK-11114-02
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: JASON KOZAL
Notification Date: 09/15/2009
Notification Time: 10:14 [ET]
Event Date: 09/15/2009
Event Time: 00:00 [CDT]
Last Update Date: 09/15/2009
Notification Time: 10:14 [ET]
Event Date: 09/15/2009
Event Time: 00:00 [CDT]
Last Update Date: 09/15/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RYAN LANTZ (R4DO)
ANGELA MCINTOSH (FSME)
RYAN LANTZ (R4DO)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE - POTENTIAL OVEREXPOSURE EVENT
The following was provided by the State via e-mail:
"A radiographer assistant employed by the company for about ten months may have been overexposed. The licensee processes dosimetry every two weeks. The employee's badge for 8-1 to 8-15 returned a reading of 3.077 rem deep dose for the two week period. This placed the employee's total exposure for the calendar year at 3.93 rem. The licensee removed the worker from being involved with licensed materials and initiated an investigation. The worker's badge for 8-16 to 8-31 had already been submitted for processing. On 9/3/09, the licensee was contacted by the dosimetry provider and informed that the worker's deep dose for 8-16 to 8-31 was 12.542 rem. This placed his total annual dose at 16 rem. No unusual exposures on the worker's pocket dosimeter had been recorded at any time. The dosimetry provider indicates the badge exposures are 'irregular'.
"The licensee contacted Oklahoma DEQ and initiated a thorough investigation. During the period in question, the radiographer assistant had worked with only one radiographer. All work was done at temporary job sites at industrial facilities. The radiographer and assistant insisted that there had been no unusual events or possibility of exposure, that the worker's alarming rate meter had not alarmed, and that pocket dosimeter readings for the period had been normal. The worker insisted he had not been exposed, and he believed someone else had exposed his dosimetry. The company does not allow assistant radiographers to have keys to cameras, and the worker is not approved for unescorted access to IC quantities of radioactive material. Both workers agreed that the assistant radiographer had never had a key to a camera, but investigation revealed that the assistant radiographer had left the worker alone with the unlocked camera while he went to the restroom. The licensee has counseled the radiographer not to do this, and has informed all radiography staff that assistant radiographers must not be left alone with unlocked radiography cameras. The licensee has contacted local medical assistance, and is told that because of the (relatively) low level of the exposure, and it being spread into at least two components, locally-available blood testing will not reliably detect the exposure.
"Since receipt of the dosimetry report, the licensee is not allowing the worker to work near radioactive materials or x-ray. The licensee does not believe the worker was actually exposed to radioactive material, and wants to use chromosome analysis to test this theory. The State has encouraged the licensee to take steps to investigate whether the exposure was to the badge only, or to the worker."
The following was provided by the State via e-mail:
"A radiographer assistant employed by the company for about ten months may have been overexposed. The licensee processes dosimetry every two weeks. The employee's badge for 8-1 to 8-15 returned a reading of 3.077 rem deep dose for the two week period. This placed the employee's total exposure for the calendar year at 3.93 rem. The licensee removed the worker from being involved with licensed materials and initiated an investigation. The worker's badge for 8-16 to 8-31 had already been submitted for processing. On 9/3/09, the licensee was contacted by the dosimetry provider and informed that the worker's deep dose for 8-16 to 8-31 was 12.542 rem. This placed his total annual dose at 16 rem. No unusual exposures on the worker's pocket dosimeter had been recorded at any time. The dosimetry provider indicates the badge exposures are 'irregular'.
"The licensee contacted Oklahoma DEQ and initiated a thorough investigation. During the period in question, the radiographer assistant had worked with only one radiographer. All work was done at temporary job sites at industrial facilities. The radiographer and assistant insisted that there had been no unusual events or possibility of exposure, that the worker's alarming rate meter had not alarmed, and that pocket dosimeter readings for the period had been normal. The worker insisted he had not been exposed, and he believed someone else had exposed his dosimetry. The company does not allow assistant radiographers to have keys to cameras, and the worker is not approved for unescorted access to IC quantities of radioactive material. Both workers agreed that the assistant radiographer had never had a key to a camera, but investigation revealed that the assistant radiographer had left the worker alone with the unlocked camera while he went to the restroom. The licensee has counseled the radiographer not to do this, and has informed all radiography staff that assistant radiographers must not be left alone with unlocked radiography cameras. The licensee has contacted local medical assistance, and is told that because of the (relatively) low level of the exposure, and it being spread into at least two components, locally-available blood testing will not reliably detect the exposure.
"Since receipt of the dosimetry report, the licensee is not allowing the worker to work near radioactive materials or x-ray. The licensee does not believe the worker was actually exposed to radioactive material, and wants to use chromosome analysis to test this theory. The State has encouraged the licensee to take steps to investigate whether the exposure was to the badge only, or to the worker."