Event Notification Report for September 26, 2008
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/25/2008 - 09/26/2008
General Information or Other
Event Number: 44523
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: GROUND TECHNOLOGY INC
Region: 4
City: HOUSTON State: TX
County:
License #: 05125
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: GROUND TECHNOLOGY INC
Region: 4
City: HOUSTON State: TX
County:
License #: 05125
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/26/2008
Notification Time: 17:24 [ET]
Event Date: 09/26/2008
Event Time: 00:00 [CDT]
Last Update Date: 09/26/2008
Notification Time: 17:24 [ET]
Event Date: 09/26/2008
Event Time: 00:00 [CDT]
Last Update Date: 09/26/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WILLIAM JONES (R4)
REBECCA TADESSE (FSME)
WILLIAM JONES (R4)
REBECCA TADESSE (FSME)
AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE
"The licensee's Radiation Safety Officer (RSO) called and informed the Agency [Texas Department of State Health Services] that a moisture density gauge had been damaged while it was being used at a work site. The worker had stored the sources in the safe condition and left the gauge at the side of the road he was working on to get a drink of water. Before he returned to the gauge, it was struck by a truck passing by on the road and the gauge rod on the top side of the gauge was bent and the gauge case was damaged. The sources both remained shielded. A service company (Component Sales) has been called to pick up the gauge and conduct an inspection of the device. The gauge is a Troxler Model 3440 ser # 23586 containing a 8 millicurie Cesium (Cs) 137 source and a 40 millicurie Americium (Am) - 241 Beryllium source."
Texas Incident # I-8566
"The licensee's Radiation Safety Officer (RSO) called and informed the Agency [Texas Department of State Health Services] that a moisture density gauge had been damaged while it was being used at a work site. The worker had stored the sources in the safe condition and left the gauge at the side of the road he was working on to get a drink of water. Before he returned to the gauge, it was struck by a truck passing by on the road and the gauge rod on the top side of the gauge was bent and the gauge case was damaged. The sources both remained shielded. A service company (Component Sales) has been called to pick up the gauge and conduct an inspection of the device. The gauge is a Troxler Model 3440 ser # 23586 containing a 8 millicurie Cesium (Cs) 137 source and a 40 millicurie Americium (Am) - 241 Beryllium source."
Texas Incident # I-8566
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital
Event Number: 44524
Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: VA MEDICAL CENTER WASHINGTON DC
Region: 1
City: WASHINGTON State: DC
County:
License #: 03-23853-01VA
Agreement: N
Docket:
NRC Notified By: ED LEIDHOLDT
HQ OPS Officer: BILL HUFFMAN
Licensee: VA MEDICAL CENTER WASHINGTON DC
Region: 1
City: WASHINGTON State: DC
County:
License #: 03-23853-01VA
Agreement: N
Docket:
NRC Notified By: ED LEIDHOLDT
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/26/2008
Notification Time: 18:15 [ET]
Event Date: 09/26/2008
Event Time: 00:00 [EDT]
Last Update Date: 12/02/2008
Notification Time: 18:15 [ET]
Event Date: 09/26/2008
Event Time: 00:00 [EDT]
Last Update Date: 12/02/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JAMNES CAMERON (R3)
REBECCA TADESSE (FSME)
JAMNES CAMERON (R3)
REBECCA TADESSE (FSME)
MEDICAL DOSE LESS THAN 80% OF PRESCRIBED DOSE
"In response to medical events discovered at the VA Medical Center Philadelphia, which have been reported under Event Number 44219, reviews are ongoing of samples of patient charts from other VA facilities with permanent prostate seed implant brachytherapy programs.
"As the result of these ongoing reviews, possible medical events were discovered on September 26, 2008, for 3 patients treated at the VA Medical Center in Washington DC.
"These 3 possible medical events involved seed distributions in the patients that may result in D90 doses less than 80% of the prescribed doses. These circumstances may meet the definition of a medical event under 10 CFR 35.3045. (The D90 is the dose that covers 90% of the volume of the prostate.)
"The VHA National Health Physics Program will ensure that the medical center follows NRC requirements for notification of the patients. These treatments and their possible effects on the patients will be reviewed by medical experts.
"A 15-day written report on these 3 possible medical events will be submitted to NRC Region III pursuant to 10 CFR 35.3045. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these possible medical events.
"The US Department of Veterans Affairs has a Master Materials License (MML) from the NRC: License No. 03-23853-01VA. Permits are issued under the MML to VA facilities. The VA submits reports to the NRC through the VHA's National Health Physics Program office located in North Little Rock, AR.
"Address of permittee involved in this event: VA Medical Center, 50 Irving Street NW, Washington DC 20422.
"The VHA permit number of the permittee involved in event: Permit No. 08-00942-05."
* * * UPDATE AT 1030 EST ON 12/02/08 FROM THOMAS HUSTON TO S. SANDIN * * *
The licensee is retracting this report based on the following:
"We are making this notification to retract medical events reported earlier under Event No. 44524. During a reactive inspection, the VA Medical Center in Washington, DC, provided the VHA National Health Physics Program with revised dose information indicating D90 doses were greater than 80% of the prescribed dose for all three patient treatments.
"We will notify our NRC Project Manager (Cassandra Frazier, Region III) of this retraction."
Notified R3DO (Kunowski) and FSME (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.
"In response to medical events discovered at the VA Medical Center Philadelphia, which have been reported under Event Number 44219, reviews are ongoing of samples of patient charts from other VA facilities with permanent prostate seed implant brachytherapy programs.
"As the result of these ongoing reviews, possible medical events were discovered on September 26, 2008, for 3 patients treated at the VA Medical Center in Washington DC.
"These 3 possible medical events involved seed distributions in the patients that may result in D90 doses less than 80% of the prescribed doses. These circumstances may meet the definition of a medical event under 10 CFR 35.3045. (The D90 is the dose that covers 90% of the volume of the prostate.)
"The VHA National Health Physics Program will ensure that the medical center follows NRC requirements for notification of the patients. These treatments and their possible effects on the patients will be reviewed by medical experts.
"A 15-day written report on these 3 possible medical events will be submitted to NRC Region III pursuant to 10 CFR 35.3045. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these possible medical events.
"The US Department of Veterans Affairs has a Master Materials License (MML) from the NRC: License No. 03-23853-01VA. Permits are issued under the MML to VA facilities. The VA submits reports to the NRC through the VHA's National Health Physics Program office located in North Little Rock, AR.
"Address of permittee involved in this event: VA Medical Center, 50 Irving Street NW, Washington DC 20422.
"The VHA permit number of the permittee involved in event: Permit No. 08-00942-05."
* * * UPDATE AT 1030 EST ON 12/02/08 FROM THOMAS HUSTON TO S. SANDIN * * *
The licensee is retracting this report based on the following:
"We are making this notification to retract medical events reported earlier under Event No. 44524. During a reactive inspection, the VA Medical Center in Washington, DC, provided the VHA National Health Physics Program with revised dose information indicating D90 doses were greater than 80% of the prescribed dose for all three patient treatments.
"We will notify our NRC Project Manager (Cassandra Frazier, Region III) of this retraction."
Notified R3DO (Kunowski) and FSME (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.