Event Notification Report for February 27, 2008
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/26/2008 - 02/27/2008
Hospital
Event Number: 44021
Rep Org: REID HOSPITAL & HEALTH CARE SERVICE
Licensee: REID HOSPITAL & HEALTH CARE SERVICES
Region: 3
City: RICHMOND State: IN
County:
License #: 13-03284-02
Agreement: N
Docket:
NRC Notified By: CHARLES NARAYANAN
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: REID HOSPITAL & HEALTH CARE SERVICES
Region: 3
City: RICHMOND State: IN
County:
License #: 13-03284-02
Agreement: N
Docket:
NRC Notified By: CHARLES NARAYANAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/29/2008
Notification Time: 14:50 [ET]
Event Date: 02/27/2008
Event Time: 11:00 [EST]
Last Update Date: 03/03/2008
Notification Time: 14:50 [ET]
Event Date: 02/27/2008
Event Time: 11:00 [EST]
Last Update Date: 03/03/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
DAVE PASSEHL (R3)
GREG MORELL (FSME)
DAVE PASSEHL (R3)
GREG MORELL (FSME)
PROSTATE TREATMENT SEEDS IMPLANTED IN UNINTENDED LOCATION
Sixty-two I-125 seeds were to be implanted in a patient's prostate. After 37 seeds were implanted, surgery was halted and the location verified as being 1-2 cm below the prostate. The hospital is evaluating the medical implications of this event. The physicians and patient were notified.
Seeds: 0.315 milliCuries each
* * * UPDATE FROM FLANNERY TO ALEXANDER AT 0713 EST ON 03/03/2008 (VIA E-MAIL) * * *
The NRC's medical events review committee has determined that is report is a medical event.
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.
Sixty-two I-125 seeds were to be implanted in a patient's prostate. After 37 seeds were implanted, surgery was halted and the location verified as being 1-2 cm below the prostate. The hospital is evaluating the medical implications of this event. The physicians and patient were notified.
Seeds: 0.315 milliCuries each
* * * UPDATE FROM FLANNERY TO ALEXANDER AT 0713 EST ON 03/03/2008 (VIA E-MAIL) * * *
The NRC's medical events review committee has determined that is report is a medical event.
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.
Other Nuclear Material
Event Number: 44010
Rep Org: ADVANCED CARE MEDICAL
Licensee: ADVANCED CARE MEDICAL
Region: 1
City: OXFORD State: CT
County:
License #: 06-30764-01
Agreement: N
Docket:
NRC Notified By: WAYNE RICHARDSON
HQ OPS Officer: JEFF ROTTON
Licensee: ADVANCED CARE MEDICAL
Region: 1
City: OXFORD State: CT
County:
License #: 06-30764-01
Agreement: N
Docket:
NRC Notified By: WAYNE RICHARDSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/27/2008
Notification Time: 15:50 [ET]
Event Date: 02/27/2008
Event Time: 10:45 [EST]
Last Update Date: 02/27/2008
Notification Time: 15:50 [ET]
Event Date: 02/27/2008
Event Time: 10:45 [EST]
Last Update Date: 02/27/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(1) - UNPLANNED CONTAMINATION
10 CFR Section:
30.50(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
LAWRENCE DOERFLEIN (R1)
MICHELE BURGESS (FSME)
LAWRENCE DOERFLEIN (R1)
MICHELE BURGESS (FSME)
UNPLANNED CONTAMINATION CAUSED BY DAMAGED I-125 SEED
During assembly of a brachytherapy seed strand in the production lab, one seed was damaged and contaminated the working tool. The seed was I-125 containing 0.399 millicuries. Contamination levels of the working tool was determined to be 17,224 dpm. Decontamination of the working tool was completed and restored working tool to normal background levels. The other 82 seeds that were in the vicinity of the working tool have been quarantined.
During assembly of a brachytherapy seed strand in the production lab, one seed was damaged and contaminated the working tool. The seed was I-125 containing 0.399 millicuries. Contamination levels of the working tool was determined to be 17,224 dpm. Decontamination of the working tool was completed and restored working tool to normal background levels. The other 82 seeds that were in the vicinity of the working tool have been quarantined.
General Information or Other
Event Number: 44011
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CIRCLE INCORPORATED
Region: 4
City: WESTWEGO State: LA
County:
License #: LA-6627-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: CIRCLE INCORPORATED
Region: 4
City: WESTWEGO State: LA
County:
License #: LA-6627-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/27/2008
Notification Time: 16:15 [ET]
Event Date: 02/27/2008
Event Time: 00:00 [CST]
Last Update Date: 02/27/2008
Notification Time: 16:15 [ET]
Event Date: 02/27/2008
Event Time: 00:00 [CST]
Last Update Date: 02/27/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
VIVIAN CAMPBELL (R4)
MICHELE BURGESS (NMSS)
ILTAB (E-MAIL)
VIVIAN CAMPBELL (R4)
MICHELE BURGESS (NMSS)
ILTAB (E-MAIL)
AGREEMENT STATE REPORT - MISSING MOISTURE DENSITY GAUGE
The State provided the following information via facsimile:
"On February 27, 2008, Circle Inc. discovered that a Troxler nuclear gauge with a 9 mCi source of Cs-137 (s/n 50-9134) and a 44 mCi source of Am-241 (s/n 47-14943) was missing from a construction site on the levee near Nicole and Lapalco in Westwego, LA. The incident is under investigation and additional information will be forwarded once it is received."
Louisiana Event Report: LA080004
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.
The State provided the following information via facsimile:
"On February 27, 2008, Circle Inc. discovered that a Troxler nuclear gauge with a 9 mCi source of Cs-137 (s/n 50-9134) and a 44 mCi source of Am-241 (s/n 47-14943) was missing from a construction site on the levee near Nicole and Lapalco in Westwego, LA. The incident is under investigation and additional information will be forwarded once it is received."
Louisiana Event Report: LA080004
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.