Event Notification Report for February 15, 2016
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/14/2016 - 02/15/2016
Agreement State
Event Number: 51735
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: ST JOSEPH'S HOSPITAL
Region: 1
City: ATLANTA State: GA
County:
License #: GA 296-6
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JOHN SHOEMAKER
Licensee: ST JOSEPH'S HOSPITAL
Region: 1
City: ATLANTA State: GA
County:
License #: GA 296-6
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/15/2016
Notification Time: 08:47 [ET]
Event Date: 02/15/2016
Event Time: 00:00 [EST]
Last Update Date: 02/15/2016
Notification Time: 08:47 [ET]
Event Date: 02/15/2016
Event Time: 00:00 [EST]
Last Update Date: 02/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION
The following report was received from the State of Georgia via email:
"The following was reported to the State of Georgia on February 15, 2016.
"The patient was prepped for the delivery of doses of 18 and 21 Gy to 14 subcentimeter brain metastases with Gamma Knife stereotactic radiosurgery. The frame adapter was placed on the patient's stereotactic head frame by a Gamma Knife trained registered nurse, supervised by Authorized Medical Physicist [AMP], and Authorized User [AU]. After five of the planned 14 lesions were treated, the patient was given a break in order to use the restroom and for additional medication. During this treatment break, the AU and AMP entered the room to release the patient from the restraining device and assist [the patient] to the rest room. It was at that point that it was discovered that the restraining device was locked, but not in the correct position. The displaced distance was measured and determined to be a maximum discrepancy of 2 cm in one plane. The AMP and AU applied the displacement to the treatment plan to determine which areas were treated and which were not. It was determined that a potential misadministration had occurred.
"The RSO [Radiation Safety Officer] was notified to discuss the course of action. Following discussions with the AMP, AU, the medical director, the prescribing physician and radiation safety officer, it was decided that there was a potential medical event or misadministration as defined in 391-3-17-.05(115)(a)3 or 391-3-17-.05(115)(b).
"The cause of the event is uncertain at this time. The head restraining device should not have been able to be secured unless it was in the proper position. An investigation is ongoing and additional information is being sought.
"The patient received an unintended radiation dose to normal brain tissue, however, it was determined by the authorized user in consult with the medical physicist that little clinical effect will be demonstrated due to this inadvertent exposure. The patient, the patient's family and the patient's referring physician were informed of the event. After extensive discussions, it was agreed by all parties that the treatment would be completed to ensure that the correct dose is delivered to the remaining target areas.
"This is all the data available at the moment. A reactive inspection is currently underway and updates are soon to follow."
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.
The following report was received from the State of Georgia via email:
"The following was reported to the State of Georgia on February 15, 2016.
"The patient was prepped for the delivery of doses of 18 and 21 Gy to 14 subcentimeter brain metastases with Gamma Knife stereotactic radiosurgery. The frame adapter was placed on the patient's stereotactic head frame by a Gamma Knife trained registered nurse, supervised by Authorized Medical Physicist [AMP], and Authorized User [AU]. After five of the planned 14 lesions were treated, the patient was given a break in order to use the restroom and for additional medication. During this treatment break, the AU and AMP entered the room to release the patient from the restraining device and assist [the patient] to the rest room. It was at that point that it was discovered that the restraining device was locked, but not in the correct position. The displaced distance was measured and determined to be a maximum discrepancy of 2 cm in one plane. The AMP and AU applied the displacement to the treatment plan to determine which areas were treated and which were not. It was determined that a potential misadministration had occurred.
"The RSO [Radiation Safety Officer] was notified to discuss the course of action. Following discussions with the AMP, AU, the medical director, the prescribing physician and radiation safety officer, it was decided that there was a potential medical event or misadministration as defined in 391-3-17-.05(115)(a)3 or 391-3-17-.05(115)(b).
"The cause of the event is uncertain at this time. The head restraining device should not have been able to be secured unless it was in the proper position. An investigation is ongoing and additional information is being sought.
"The patient received an unintended radiation dose to normal brain tissue, however, it was determined by the authorized user in consult with the medical physicist that little clinical effect will be demonstrated due to this inadvertent exposure. The patient, the patient's family and the patient's referring physician were informed of the event. After extensive discussions, it was agreed by all parties that the treatment would be completed to ensure that the correct dose is delivered to the remaining target areas.
"This is all the data available at the moment. A reactive inspection is currently underway and updates are soon to follow."
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.
Non-Agreement State
Event Number: 51736
Rep Org: DOMINION RESOURCES SERVICES
Licensee: DOMINION TRANSMISSION, INC.
Region: 1
City: JANE LEW State: WV
County:
License #:
Agreement: N
Docket:
NRC Notified By: RAY HUGO
HQ OPS Officer: JEFF HERRERA
Licensee: DOMINION TRANSMISSION, INC.
Region: 1
City: JANE LEW State: WV
County:
License #:
Agreement: N
Docket:
NRC Notified By: RAY HUGO
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/16/2016
Notification Time: 10:05 [ET]
Event Date: 02/15/2016
Event Time: 00:00 [EST]
Last Update Date: 02/16/2016
Notification Time: 10:05 [ET]
Event Date: 02/15/2016
Event Time: 00:00 [EST]
Last Update Date: 02/16/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
LOST TRITIUM EXIT SIGNS
"Pursuant to Federal Regulation 10 CFR 31.5(a), Dominion Transmission, Inc. is a general licensee of the NRC because it possesses and uses byproduct material in the form of tritium exit signs (TES). Consistent with Federal requirements, Dominion is providing the subject report regarding two (2) lost TES.
"Dominion has established a company-wide program to inventory TES. Inventory efforts have identified that the following TES which were present at the previous inventory cannot be located and are presumed lost:
"Serial Number: CO563528
Model Number: BX
Activity: 20 Curies
"Serial Number: CO563530
Model Number: BX
Activity: 20 Curies
"Dominion conducted this most recent inventory during a recent construction re-modeling project involving the building of a new addition at its Lightburn Station. Dominion has no information that these TES have been transferred. Accordingly, and in addition to physical searches for the TES conducted by Dominion, Dominion interviewed key on-site personnel, contractors and vendors who had worked on the site. Interviewed personnel include the Dominion project manager, site safety personnel and the lead contractor who performed the demolition. None of these interviewees recall disposing of the TES.
"Dominion also contacted the local trash removal services (C and D Dumpster) and they have confirmed that a dumpster was removed from the site during the remodeling project. Dominion therefore contacted S and S Landfill. S and S Landfill has no equipment available to monitor for radiation levels and consequently could not provide us with any relevant information as to the possible disposition of these TES.
"As a result of these investigative efforts, Dominion concluded that these TES are lost. We have also confirmed that all other TES are currently in place at the Lightburn Station facility."
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
"Pursuant to Federal Regulation 10 CFR 31.5(a), Dominion Transmission, Inc. is a general licensee of the NRC because it possesses and uses byproduct material in the form of tritium exit signs (TES). Consistent with Federal requirements, Dominion is providing the subject report regarding two (2) lost TES.
"Dominion has established a company-wide program to inventory TES. Inventory efforts have identified that the following TES which were present at the previous inventory cannot be located and are presumed lost:
"Serial Number: CO563528
Model Number: BX
Activity: 20 Curies
"Serial Number: CO563530
Model Number: BX
Activity: 20 Curies
"Dominion conducted this most recent inventory during a recent construction re-modeling project involving the building of a new addition at its Lightburn Station. Dominion has no information that these TES have been transferred. Accordingly, and in addition to physical searches for the TES conducted by Dominion, Dominion interviewed key on-site personnel, contractors and vendors who had worked on the site. Interviewed personnel include the Dominion project manager, site safety personnel and the lead contractor who performed the demolition. None of these interviewees recall disposing of the TES.
"Dominion also contacted the local trash removal services (C and D Dumpster) and they have confirmed that a dumpster was removed from the site during the remodeling project. Dominion therefore contacted S and S Landfill. S and S Landfill has no equipment available to monitor for radiation levels and consequently could not provide us with any relevant information as to the possible disposition of these TES.
"As a result of these investigative efforts, Dominion concluded that these TES are lost. We have also confirmed that all other TES are currently in place at the Lightburn Station facility."
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