Event Notification Report for November 30, 2001
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/29/2001 - 11/30/2001
General Information or Other
Event Number: 38536
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: GOOD SAMARITAN REGIONAL MEDICAL CENTER
Region: 4
City: PHOENIX State: AZ
County:
License #: 07-478
Agreement: Y
Docket:
NRC Notified By: AUBREY GODWIN
HQ OPS Officer: FANGIE JONES
Licensee: GOOD SAMARITAN REGIONAL MEDICAL CENTER
Region: 4
City: PHOENIX State: AZ
County:
License #: 07-478
Agreement: Y
Docket:
NRC Notified By: AUBREY GODWIN
HQ OPS Officer: FANGIE JONES
Notification Date: 12/04/2001
Notification Time: 15:46 [ET]
Event Date: 11/30/2001
Event Time: 00:00 [MST]
Last Update Date: 12/04/2001
Notification Time: 15:46 [ET]
Event Date: 11/30/2001
Event Time: 00:00 [MST]
Last Update Date: 12/04/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ANTHONY GODY (R4)
JOHN HICKEY (NMSS)
MARK LESSER (R2)
ANTHONY GODY (R4)
JOHN HICKEY (NMSS)
MARK LESSER (R2)
AGREEMENT STATE REPORT - RELEASE OF 5 SOURCES
The following is taken from a faxed report:
This First Notice constitutes early notice of events of possible safety or public interest significance. The information is as initially received without verification or evaluation, and is basically all that is known by the Agency Staff at this time.
Date: December 4, 2001, Time: 12:30 PM (MST), First Notice 01-11
Arizona Licensee: Good Samaritan Regional Medical Center, License No. 07-478
On November 30, 2001 the Arizona Radiation Regulatory Agency was notified of a release of 5 sources of Strontium 90. The Licensee was utilizing a Novoste Beta-Cath system model A1732 with a BEBIG, model No. SrO.SO3 with 12 sources and 60 millicuries in the train. As apart of the Licensee's preparation, the source train was being test run in the device. The Licensee noted the sterile water was less resistant to injection and found a leak. He then retrieved the sources and heard the solenoid click indicating the sources were back in a safe position. The catheter was removed. While checking the system to determine the cause of the leak, the Licensee noted 5 sources were on the floor. The Licensee instituted an inventory and could clearly identify 11 sources with a possible location of the 12th. The Agency assisted the Licensee and determined that all sources were accounted for and approved the return of the device to the manufacturer. The manufacturer is to determine why the device signaled all sources had returned and why one source was trapped within the device. The State of Georgia has been notified of the details of this incident.
Agency continues to investigate this event.
The State of Georgia,, together with the U.S. NRC, are being notified of this event.
The following is taken from a faxed report:
This First Notice constitutes early notice of events of possible safety or public interest significance. The information is as initially received without verification or evaluation, and is basically all that is known by the Agency Staff at this time.
Date: December 4, 2001, Time: 12:30 PM (MST), First Notice 01-11
Arizona Licensee: Good Samaritan Regional Medical Center, License No. 07-478
On November 30, 2001 the Arizona Radiation Regulatory Agency was notified of a release of 5 sources of Strontium 90. The Licensee was utilizing a Novoste Beta-Cath system model A1732 with a BEBIG, model No. SrO.SO3 with 12 sources and 60 millicuries in the train. As apart of the Licensee's preparation, the source train was being test run in the device. The Licensee noted the sterile water was less resistant to injection and found a leak. He then retrieved the sources and heard the solenoid click indicating the sources were back in a safe position. The catheter was removed. While checking the system to determine the cause of the leak, the Licensee noted 5 sources were on the floor. The Licensee instituted an inventory and could clearly identify 11 sources with a possible location of the 12th. The Agency assisted the Licensee and determined that all sources were accounted for and approved the return of the device to the manufacturer. The manufacturer is to determine why the device signaled all sources had returned and why one source was trapped within the device. The State of Georgia has been notified of the details of this incident.
Agency continues to investigate this event.
The State of Georgia,, together with the U.S. NRC, are being notified of this event.
Hospital
Event Number: 38527
Rep Org: GENESYS REGIONAL MEDICAL CENTER
Licensee: GENESYS REGIONAL MEDICAL CENTER
Region: 3
City: GRAND BLANC State: MI
County:
License #: 21-26740-01
Agreement: N
Docket:
NRC Notified By: FREDERICK
HQ OPS Officer: CHAUNCEY GOULD
Licensee: GENESYS REGIONAL MEDICAL CENTER
Region: 3
City: GRAND BLANC State: MI
County:
License #: 21-26740-01
Agreement: N
Docket:
NRC Notified By: FREDERICK
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 11/30/2001
Notification Time: 12:03 [ET]
Event Date: 11/30/2001
Event Time: 09:30 [EST]
Last Update Date: 11/30/2001
Notification Time: 12:03 [ET]
Event Date: 11/30/2001
Event Time: 09:30 [EST]
Last Update Date: 11/30/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(2) - EXTERNAL RAD LEVELS > LIMITS
10 CFR Section:
20.1906(d)(2) - EXTERNAL RAD LEVELS > LIMITS
Person (Organization):
BRUCE JORGENSEN (R3)
BRUCE JORGENSEN (R3)
INCORRECT SHIPPING PACKAGE USED FOR SHIPPING I-133 TO THE MEDICAL FACILITY
The Genesys Regional Medical Center received a shipment of 156 millicuries of I-133 from Syncor International in Flint, Mi. that was packaged in a Yellow - 2 package. Yellow - 2 packages have a 50 mr/hr limit for transporting radiological materials. Syncor had monitored the shipment as 80 mr/hr and the medical facility monitored it at 100 mr/hr. Therefore, it should have been shipped in another type of package(possibly a Yellow - 3). There was no contamination measured. Syncor was notified of this error by the medical center.
The Genesys Regional Medical Center received a shipment of 156 millicuries of I-133 from Syncor International in Flint, Mi. that was packaged in a Yellow - 2 package. Yellow - 2 packages have a 50 mr/hr limit for transporting radiological materials. Syncor had monitored the shipment as 80 mr/hr and the medical facility monitored it at 100 mr/hr. Therefore, it should have been shipped in another type of package(possibly a Yellow - 3). There was no contamination measured. Syncor was notified of this error by the medical center.