Event Notification Report for June 24, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/23/2015 - 06/24/2015
EVENT NUMBERS
51197
Agreement State
Event Number: 51197
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: NORTHWEST HOSPITAL, L.L.C.
Region: 4
City: TUCSON State: AZ
County:
License #: AZ 10-097
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: STEVEN VITTO
Licensee: NORTHWEST HOSPITAL, L.L.C.
Region: 4
City: TUCSON State: AZ
County:
License #: AZ 10-097
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: STEVEN VITTO
Notification Date: 07/01/2015
Notification Time: 17:05 [ET]
Event Date: 06/24/2015
Event Time: 08:00 [MST]
Last Update Date: 07/02/2015
Notification Time: 17:05 [ET]
Event Date: 06/24/2015
Event Time: 08:00 [MST]
Last Update Date: 07/02/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
NEIL OKEEFE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
NEIL OKEEFE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - TWO POTENTIALLY LOST IODINE-125 SEEDS
The following information was obtained from the State of Arizona via email:
"At approximately 0800 [MST] on July 1, 2015, the licensee reported that two (2) 0.256 millicurie Iodine-125 seeds were potentially lost on June 24, 2015. The licensee stated that while implanting 84 I-125 seeds into a patient in the operating room, the doctor realized that one of the syringes, which was supposed to have two (2) I-125 seeds in it, was empty. The licensee surveyed the entire operating room and hot lab but did not locate the seeds. The manufacturer was also contacted in an attempt to see if the syringe was shipped to the licensee without the seeds in it.
"The Agency [Arizona Radiation Regulatory Agency] is investigating the event.
"The Governor's Office is being notified of this event."
Arizona First Notice: 15-012
* * * UPDATE ON 7/2/15 AT 1741 EDT FROM BRIAN GORETZKI TO JEFF HERRERA * * *
The following update was provided by the Arizona Radiation Regulatory Agency via email:
"On July 2, 2015, the two lost seeds were discovered to be actually implanted into the patient. After a review of the new CT scan, the licensee was able to identify that all 84 seeds were in the patient."
Notified the R4DO (Okeefe) and NMSS Events (via email).
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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
The following information was obtained from the State of Arizona via email:
"At approximately 0800 [MST] on July 1, 2015, the licensee reported that two (2) 0.256 millicurie Iodine-125 seeds were potentially lost on June 24, 2015. The licensee stated that while implanting 84 I-125 seeds into a patient in the operating room, the doctor realized that one of the syringes, which was supposed to have two (2) I-125 seeds in it, was empty. The licensee surveyed the entire operating room and hot lab but did not locate the seeds. The manufacturer was also contacted in an attempt to see if the syringe was shipped to the licensee without the seeds in it.
"The Agency [Arizona Radiation Regulatory Agency] is investigating the event.
"The Governor's Office is being notified of this event."
Arizona First Notice: 15-012
* * * UPDATE ON 7/2/15 AT 1741 EDT FROM BRIAN GORETZKI TO JEFF HERRERA * * *
The following update was provided by the Arizona Radiation Regulatory Agency via email:
"On July 2, 2015, the two lost seeds were discovered to be actually implanted into the patient. After a review of the new CT scan, the licensee was able to identify that all 84 seeds were in the patient."
Notified the R4DO (Okeefe) and NMSS Events (via email).
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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf