United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for January 20, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/19/2012 - 01/20/2012

** EVENT NUMBERS **


47593 47597 47598 47606

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Agreement State Event Number: 47593
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: MEMORIAL HERMANN HOUSTON
Region: 4
City: HOUSTON State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: BOB FREE
HQ OPS Officer: VINCE KLCO
Notification Date: 01/13/2012
Notification Time: 18:27 [ET]
Event Date: 01/13/2012
Event Time: [CST]
Last Update Date: 01/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
RICHARD TURTIL (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT

A patient of Memorial Hermann in Houston received the wrong radioisotope. A dose of Gallium-67 was ordered, but a dose of Thallium-201 was delivered. Because the dose was improperly labeled as Gallium-67, the dose calibration process indicated an acceptable radioisotope and dose. The patient was injected with the wrong radioisotope on January 11, 2012. During patient imaging on January 13, 2012, it was realized that the patient received the wrong radioisotope. The pharmacy was notified of the error and admitted to delivery of the wrong isotope. The physicist at the hospital estimates that the patient received a dose of about 6 REM whole body.

Texas Incident Number: I-8921

* * * UPDATED AT 1434 EST ON 01/17/12 FROM ROBERT FREE TO S. SANDIN * * *

The following information was received as an update:

"The licensee called to report that the wrong isotope was administered to a patient. Thallium 201 had been injected in a patient instead of Gallium 67 that was ordered. Apparently, the pharmacy sent the wrong isotope. 8 mCi of Gallium was ordered and a estimated 4.7 mCi of Thallium was delivered. Dose activities were similar and the dose calibrator didn't pick up the difference in isotope. Patient was injected on 1/11/12 and imaged 1/13/12. The mistake was discovered in imaging. The licensee will file a written report within 15 days."

Notified R4DO (Pick) and FSME (McIntosh).

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.

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Agreement State Event Number: 47597
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: PENNTECK DIAGNOSTICS, INC.
Region: 1
City: MARTINEZ State: GA
County:
License #: GA975-1
Agreement: Y
Docket:
NRC Notified By: KEITH V. ST. CYR
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/17/2012
Notification Time: 10:12 [ET]
Event Date: 01/07/2012
Event Time: 10:30 [EST]
Last Update Date: 01/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RONALD BELLAMY (R1DO)
RICHARD TURTIL (FSME)
MATTHEW HAHN (ILTA)

Event Text

AGREEMENT STATE REPORT - ATTEMPTED THEFT OF MEDICAL IMAGING EQUIPMENT

The following information was received from the State of Georgia:

On January 17, 2012 the State of Georgia received a fax dated January 13, 2012, from one of their licensees (PennTeck Diagnostics, Inc., license number GA 975-1) that one of their two mobile nuclear vans was broken into on Saturday, January 7, 2012, at 1030 EST, but nothing was stolen. PennTeck Diagnostics is located in Augusta, Georgia.

The State contacted the licensee this morning to see if any further details or clarification on the incident could be gathered, but no additional information was given. The licensee reiterated that all of their calibration sealed sources and flood source were accounted for; they installed new locks on the rear lift gate on the mobile van where the thief entered, and the police are looking over the surveillance tapes.

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Agreement State Event Number: 47598
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: NDE SOLUTIONS, LLC
Region: 4
City:  State: TX
County: GONZALES
License #: L05879
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/17/2012
Notification Time: 11:01 [ET]
Event Date: 01/14/2012
Event Time: 13:30 [CST]
Last Update Date: 01/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - SOURCE DISCONNECTED FROM RADIOGRAPHY CAMERA

The following report was received by fax:

"On January 17, 2012, the Agency [Texas Department of State Health Services] was notified by the licensee of a source disconnect event that occurred on January 14, 2012. The radiography crew was using a QSA 880D containing 54.9 Curies of iridium-192. The drive cables were also manufactured by QSA. The disconnect was caused by the drive cable snapping approximately four inches from the source connector. The radiographer noted the failure as he approached the camera after a shot and the dose rates indicated the source was still outside the camera. The radiographer notified his Radiation Safety Officer (RSO). The radiography crew set up new barriers and controlled access to the area. The RSO arrived at the site at 1630 hours. The RSO retrieved the source and it was returned to the fully shielded position by 1730 hours. The RSO stated that there was a section of the drive cable that looked like it may have been stretched, but he did not know when or how it could have happened. He stated that they had only had this set of drive cables for no more than eight months. No exposure limits were exceeded during this event. Additional information will be provided as it is received in accordance with SA-300."

The event occurred on County Road 289 in Gonzales County.

Texas incident: I-8922

* * * UPDATE AT 1321 EST ON 01/17/12 FROM ART TUCKER TO S. SANDIN * * *

"The licensee has stated that the drive cable will be returned to the manufacturer for inspection and a cause for the failure [investigation].

Notified R4DO (Pick) and FSME (McIntosh).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 47606
Rep Org: U.S.ARMY TACOM LIFE CYCLE COMMAND
Licensee: U.S. ARMY NATIONAL GUARD
Region: 3
City: WARREN State: MI
County:
License #: 21-32838-01
Agreement: N
Docket:
NRC Notified By: KAREN MCGUIRE
HQ OPS Officer: JOE O'HARA
Notification Date: 01/18/2012
Notification Time: 15:41 [ET]
Event Date: 01/18/2012
Event Time: 13:24 [EST]
Last Update Date: 01/19/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
HIRONORI PETERSON (R3DO)
RONALD BELLAMY (R1DO)
BRUCE WATSON (FSME)

Event Text

POTENTIALLY DAMAGED RANGE INDICATOR CONTAINING 3.2 CURIES TRITIUM

The U.S. Army Life Cycle Command was informed by the Combined Support Maintenance Shop in Richmond, Virginia that a range indicator containing 4 sources of 0.8 Curies each of Tritium may be damaged. Apparently, the range indicators appear cracked and are not illuminating properly. The range indicator is locked inside a secured area with no access allowed. The U.S. Army is waiting for results of swipe surveys to determine if there is an actual spread of contamination.

* * * RETRACTION FROM THOMAS GIZICKI TO JOE O'HARA AT 1302 EST ON 1/19/12 * * *

The licensee is retracting the event based upon swipe survey results being less than the lower limit of detectability. There was no spread of contamination and the device will be disposed of in the future.

The licensee notified Bill Lin (Region 3).

Notified R3DO(Peterson), R1DO(Bellamy) and FSME(McIntosh).

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012