Event Notification Report for November 05, 2006
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/04/2006 - 11/05/2006
EVENT NUMBERS
42965
General Information or Other
Event Number: 42965
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: BEN TAUB GENERAL HOSPITAL
Region: 4
City: HOUSTON State: TX
County:
License #: L01303
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: JOHN MacKINNON
Licensee: BEN TAUB GENERAL HOSPITAL
Region: 4
City: HOUSTON State: TX
County:
License #: L01303
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: JOHN MacKINNON
Notification Date: 11/05/2006
Notification Time: 18:07 [ET]
Event Date: 11/05/2006
Event Time: 16:00 [CST]
Last Update Date: 11/06/2006
Notification Time: 18:07 [ET]
Event Date: 11/05/2006
Event Time: 16:00 [CST]
Last Update Date: 11/06/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL SHANNON (R4)
ED HACKETT (NMSS)
MICHAEL SHANNON (R4)
ED HACKETT (NMSS)
TEXAS AGREEMENT STATE REPORT - MISSING SOURCE
Two Radiation Oncologist Residents removed an LDR applicator from a cervical cancer patient. The applicator was supposed to have contained four Cesium-137 sources, 15 millicuries each, but only 3 of the sources were found. The patient's bed sheets had been changed and taken out of the room. Search for missing source is in progress.
* * * UPDATE FROM R. JISHA TO P. SNYDER AT 0843 ON 11/6/06 * * *
The lost source material was found in the laundry. The state continues to investigate. Further information will be provided later.
Notified R4DO (J. Clark) and NMSS EO (M. Burgess).
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.
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.
Two Radiation Oncologist Residents removed an LDR applicator from a cervical cancer patient. The applicator was supposed to have contained four Cesium-137 sources, 15 millicuries each, but only 3 of the sources were found. The patient's bed sheets had been changed and taken out of the room. Search for missing source is in progress.
* * * UPDATE FROM R. JISHA TO P. SNYDER AT 0843 ON 11/6/06 * * *
The lost source material was found in the laundry. The state continues to investigate. Further information will be provided later.
Notified R4DO (J. Clark) and NMSS EO (M. Burgess).
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.
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.