Event Notification Report for August 30, 2010
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/29/2010 - 08/30/2010
Hospital
Event Number: 46224
Rep Org: PROVIDENCE HOSPITAL
Licensee: PROVIDENCE HOSPITAL
Region: 3
City: NOVI State: MI
County:
License #: 21-02802-03
Agreement: N
Docket:
NRC Notified By: VRINDA NARAYANA
HQ OPS Officer: ERIC SIMPSON
Licensee: PROVIDENCE HOSPITAL
Region: 3
City: NOVI State: MI
County:
License #: 21-02802-03
Agreement: N
Docket:
NRC Notified By: VRINDA NARAYANA
HQ OPS Officer: ERIC SIMPSON
Notification Date: 09/02/2010
Notification Time: 13:30 [ET]
Event Date: 08/30/2010
Event Time: 14:00 [EDT]
Last Update Date: 09/14/2010
Notification Time: 13:30 [ET]
Event Date: 08/30/2010
Event Time: 14:00 [EDT]
Last Update Date: 09/14/2010
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):
TAMARA BLOOMER (R3DO)
ANGELA MCINTOSH (FSME)
TAMARA BLOOMER (R3DO)
ANGELA MCINTOSH (FSME)
MISPLACED PALLIATIVE SOURCE IMPLANTS
On August 30, 2010, a patient was implanted with I-125 seeds in the anus for a palliative procedure. Two days later, September 1, 2010, a follow-up CT scan on the patient showed that the implants had been inserted 4 cm superior to the intended location which would lead to less dose at the target location. The intended dose was 90 Gy to the anus.
More imaging studies are planned to estimate the actual dose to the intended target area. The patient will be implanted again after the imaging study is complete. A decision will be made at that time whether to correct the original implants.
The reason for the error is believed to be twofold: The tumor had progressed markedly since the original planning and the decision was made to correct the plan for the additional growth based on palpation indications. Also, the 10 cm mark on the needle may have been mistaken for the 5 cm mark.
No long term complications are anticipated.
Both patient and physician have been informed.
* * * UPDATE AT 1330 EDT ON 09/14/10 FROM VRINDA NARAYANA TO S. SANDIN * * *
The licensee is updating this report to provide the results of the normal tissue doses from the permanent implants at the end of the treatment plan to the following organs:
Bladder: Prescribed .07 Gy - Delivered 3.75 Gy
Seminal Vesicles: Prescribed 5.38 Gy - Delivered 25.17 Gy
Prostate: Prescribed 6.24 Gy - Delivered 4.2 Gy
Rectum: Prescribed 45.18 Gy - Delivered 3.16 Gy
The above information will be provided in the 15-day written report. Notified R3DO (Hills) 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.
On August 30, 2010, a patient was implanted with I-125 seeds in the anus for a palliative procedure. Two days later, September 1, 2010, a follow-up CT scan on the patient showed that the implants had been inserted 4 cm superior to the intended location which would lead to less dose at the target location. The intended dose was 90 Gy to the anus.
More imaging studies are planned to estimate the actual dose to the intended target area. The patient will be implanted again after the imaging study is complete. A decision will be made at that time whether to correct the original implants.
The reason for the error is believed to be twofold: The tumor had progressed markedly since the original planning and the decision was made to correct the plan for the additional growth based on palpation indications. Also, the 10 cm mark on the needle may have been mistaken for the 5 cm mark.
No long term complications are anticipated.
Both patient and physician have been informed.
* * * UPDATE AT 1330 EDT ON 09/14/10 FROM VRINDA NARAYANA TO S. SANDIN * * *
The licensee is updating this report to provide the results of the normal tissue doses from the permanent implants at the end of the treatment plan to the following organs:
Bladder: Prescribed .07 Gy - Delivered 3.75 Gy
Seminal Vesicles: Prescribed 5.38 Gy - Delivered 25.17 Gy
Prostate: Prescribed 6.24 Gy - Delivered 4.2 Gy
Rectum: Prescribed 45.18 Gy - Delivered 3.16 Gy
The above information will be provided in the 15-day written report. Notified R3DO (Hills) 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.
General Information or Other
Event Number: 46332
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: LEE TESTING & ENGINEERING, INC
Region: 3
City: HILLIARD State: OH
County:
License #: OH31210250011
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: HOWIE CROUCH
Licensee: LEE TESTING & ENGINEERING, INC
Region: 3
City: HILLIARD State: OH
County:
License #: OH31210250011
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/14/2010
Notification Time: 13:43 [ET]
Event Date: 08/30/2010
Event Time: 00:00 [EDT]
Last Update Date: 11/09/2010
Notification Time: 13:43 [ET]
Event Date: 08/30/2010
Event Time: 00:00 [EDT]
Last Update Date: 11/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MONTE PHILLIPS (R3DO)
ANGELA MCINTOSH (FSME)
MONTE PHILLIPS (R3DO)
ANGELA MCINTOSH (FSME)
OHIO AGREEMENT STATE REPORT - ABANDONED MOISTURE DENSITY GAUGES
The following information was obtained from the State of Ohio via email:
"On August 11, 2010, the licensee submitted a request to [the State of Ohio to] terminate their portable gauge license. On September 9, 2010, the Ohio Department of Health (ODH) was notified by a third party that Lee Testing had vacated the premises at 3530 Parkway Lane and had left behind a total of seven (7) devices containing radioactive materials. Upon contacting the building owner, it was determined that the licensee had moved out of the building sometime during the prior week, and that the keys to the building and its contents were relinquished to the building owner.
"On September 13, 2010, representatives from ODH and a licensed service provider visited the 3530 Parkway Lane location and removed the seven devices present at that location. This removal was determined to be necessary as authorized under rule 3701:1-38-06(E) of the Ohio Administrative Code (OAC). The seven devices are currently in a safe and secure storage location pending a decision on final disposition.
"ODH is conducting an ongoing investigation.
"The NRC Registry of Radioactive Sealed Sources and Devices indicates that [three Troxler Model] 3411-B gauges contain a Cs-137 source with a maximum activity of 0.33 GBq (9 mCi) and an Am-Be source with a maximum activity of 1.63 GBq (44 mCi). The Registry indicates that [Troxler Model] 3241-C gauge contains an Am-Be source with a maximum activity of 11.1 GBq (300 mCi). The Registry also indicates that the [three Humboldt Scientific Model] 5001 gauges contain a Cs-137 source with a maximum activity of 0.41 GBq (11 mCi) and an Am-Be source with a maximum activity of 1.63 GBq (44 mCi)."
Ohio Report Number: OH100494
* * * UPDATE FROM STEPHEN JAMES TO JOHN KNOKE AT 1212 EST ON 11/09/10 * * *
The state of Ohio provided serial numbers for the following sources:
Source Number: 1
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 47-2403
Radionuclide or Voltage (kVp/MeV): AM-241
Source Number: 10
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 508801
Radionuclide or Voltage (kVp/MeV): CS-137
Source Number: 11
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: NJ00192
Radionuclide or Voltage (kVp/MeV): AM-241
Source Number: 12
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 5843GF
Radionuclide or Voltage (kVp/MeV): CS-137
Source Number: 13
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: NJ00663
Radionuclide or Voltage (kVp/MeV): AM-241
Source Number: 14
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 1195GH
Radionuclide or Voltage (kVp/MeV): CS-137
Source Number: 2
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 00009159
Radionuclide or Voltage (kVp/MeV): CS-137
Source Number: 3
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 475790
Radionuclide or Voltage (kVp/MeV): AM-241
Source Number: 4
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 406594
Radionuclide or Voltage (kVp/MeV): CS-137
Source Number: 5
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 477088
Radionuclide or Voltage (kVp/MeV): AM-241
Source Number: 6
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 409291
Radionuclide or Voltage (kVp/MeV): CS-137
Source Number: 7
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: Unknown
Radionuclide or Voltage (kVp/MeV): AM-241
Source Number: 8
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: Unknown
Radionuclide or Voltage (kVp/MeV): CS-137
Activity: Ci GBq
Source Number: 9
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: XX00166
Radionuclide or Voltage (kVp/MeV): AM-241
Ohio Item Number: OH100020
The following information was obtained from the State of Ohio via email:
"On August 11, 2010, the licensee submitted a request to [the State of Ohio to] terminate their portable gauge license. On September 9, 2010, the Ohio Department of Health (ODH) was notified by a third party that Lee Testing had vacated the premises at 3530 Parkway Lane and had left behind a total of seven (7) devices containing radioactive materials. Upon contacting the building owner, it was determined that the licensee had moved out of the building sometime during the prior week, and that the keys to the building and its contents were relinquished to the building owner.
"On September 13, 2010, representatives from ODH and a licensed service provider visited the 3530 Parkway Lane location and removed the seven devices present at that location. This removal was determined to be necessary as authorized under rule 3701:1-38-06(E) of the Ohio Administrative Code (OAC). The seven devices are currently in a safe and secure storage location pending a decision on final disposition.
"ODH is conducting an ongoing investigation.
"The NRC Registry of Radioactive Sealed Sources and Devices indicates that [three Troxler Model] 3411-B gauges contain a Cs-137 source with a maximum activity of 0.33 GBq (9 mCi) and an Am-Be source with a maximum activity of 1.63 GBq (44 mCi). The Registry indicates that [Troxler Model] 3241-C gauge contains an Am-Be source with a maximum activity of 11.1 GBq (300 mCi). The Registry also indicates that the [three Humboldt Scientific Model] 5001 gauges contain a Cs-137 source with a maximum activity of 0.41 GBq (11 mCi) and an Am-Be source with a maximum activity of 1.63 GBq (44 mCi)."
Ohio Report Number: OH100494
* * * UPDATE FROM STEPHEN JAMES TO JOHN KNOKE AT 1212 EST ON 11/09/10 * * *
The state of Ohio provided serial numbers for the following sources:
Source Number: 1
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 47-2403
Radionuclide or Voltage (kVp/MeV): AM-241
Source Number: 10
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 508801
Radionuclide or Voltage (kVp/MeV): CS-137
Source Number: 11
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: NJ00192
Radionuclide or Voltage (kVp/MeV): AM-241
Source Number: 12
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 5843GF
Radionuclide or Voltage (kVp/MeV): CS-137
Source Number: 13
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: NJ00663
Radionuclide or Voltage (kVp/MeV): AM-241
Source Number: 14
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 1195GH
Radionuclide or Voltage (kVp/MeV): CS-137
Source Number: 2
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 00009159
Radionuclide or Voltage (kVp/MeV): CS-137
Source Number: 3
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 475790
Radionuclide or Voltage (kVp/MeV): AM-241
Source Number: 4
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 406594
Radionuclide or Voltage (kVp/MeV): CS-137
Source Number: 5
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 477088
Radionuclide or Voltage (kVp/MeV): AM-241
Source Number: 6
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 409291
Radionuclide or Voltage (kVp/MeV): CS-137
Source Number: 7
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: Unknown
Radionuclide or Voltage (kVp/MeV): AM-241
Source Number: 8
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: Unknown
Radionuclide or Voltage (kVp/MeV): CS-137
Activity: Ci GBq
Source Number: 9
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: XX00166
Radionuclide or Voltage (kVp/MeV): AM-241
Ohio Item Number: OH100020