Event Notification Report for January 21, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/20/2022 - 01/21/2022
Agreement State
Event Number: 55704
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Northwestern Memorial Hospital
Region: 3
City: Chicago State: IL
County:
License #: IL-01037-02
Agreement: Y
Docket:
NRC Notified By: Robin G. Muzzalupo
HQ OPS Officer: Lloyd Desotell
Notification Date: 01/13/2022
Notification Time: 17:15 [ET]
Event Date: 02/15/2021
Event Time: 00:00 [CST]
Last Update Date: 01/13/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 1/21/2022
EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was received from Illinois Emergency Management Agency (Agency) via E-mail:
"Agency inspectors performed a routine inspection on 1/6/2022. During a review of Y-90 TheraSphere procedures, inspectors noted an unreported medical event which occurred on 2/15/2021.
"On 2/15/2021, a written directive to deliver 1.93 GBq Y-90 TheraSpheres to the right hepatic artery was prepared. The procedure performed that same day was halted prematurely due to an unwinding of the male luer lock connector and only 0.49 GBq were administered. To compensate for the underdose, the licensee created an additional written directive and administered 1.17 GBq Y-90 TheraSpheres without incident [on the same day as the initial procedure].
"The licensee was under the impression that this was not a reportable medical event since they were able to compensate the dose with an additional vial they had on hand and were ultimately able to deliver the intended dose."
Item Number: IL220001
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.
Agreement State
Event Number: 55705
Rep Org: Texas Dept of State Health Services
Licensee: Paradigm Consultants Inc.
Region: 4
City: Houston State: TX
County:
License #: L04875
Agreement: Y
Docket:
NRC Notified By: Matthew Kennington
HQ OPS Officer: Brian P. Smith
Notification Date: 01/14/2022
Notification Time: 17:13 [ET]
Event Date: 01/14/2022
Event Time: 17:00 [CST]
Last Update Date: 01/14/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Groom, Jeremy (R4)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 1/21/2022
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following report was received by the Texas Department of State Health Services [the Agency]:
"On January 14, 2022, the Agency was notified by the licensee that a Troxler model 3430 was damaged at a temporary job site. The gauge contains a 40 millicurie americium - 241 source and an 8 millicurie cesium - 137 source. The gauge was run over by a Bobcat machine, damaging the gauge body and separating the cesium source rod and handle from the base of the device. The cesium source was in the fully shielded position at the time of impact. The cesium source was determined to be intact and still attached to the source rod. The technician contacted the radiation safety officer (RSO). The RSO visually inspected the device, returned the device to its transport container, and confirmed that the radiation profile had not changed from the manufacturer's specifications. The gauge was returned to the licensee's facility. The gauge will be sent to the manufacturer. No individual received a significant exposure due to this event. Additional information will be provided as it is received in accordance with SA-300."
Texas State Incident Number: I-9910