Event Notification Report for October 21, 2016
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/20/2016 - 10/21/2016
Agreement State
Event Number: 52316
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: MIDWEST INDUSTRIAL X-RAY
Region: 3
City: WAVERLY State: MN
County:
License #: 1186-89
Agreement: Y
Docket:
NRC Notified By: MATT DUFF
HQ OPS Officer: STEVEN VITTO
Licensee: MIDWEST INDUSTRIAL X-RAY
Region: 3
City: WAVERLY State: MN
County:
License #: 1186-89
Agreement: Y
Docket:
NRC Notified By: MATT DUFF
HQ OPS Officer: STEVEN VITTO
Notification Date: 10/24/2016
Notification Time: 11:18 [ET]
Event Date: 10/21/2016
Event Time: 08:15 [CDT]
Last Update Date: 10/24/2016
Notification Time: 11:18 [ET]
Event Date: 10/21/2016
Event Time: 08:15 [CDT]
Last Update Date: 10/24/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
PATTY PELKE (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
PATTY PELKE (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - SOURCE DISCONNECT
The following was received from the State of Minnesota via email:
"At approximately 0815 CDT on Friday, 10/21/16, radiographers for Midwest Industrial X-Ray experienced a source disconnect while working on a project for Excel. The project was taking place outside of Waverly, MN, in a rural area. A 34 Ci source (serial number XF2112, model G60) of Ir-192 experienced a disconnect from a SPEC 150 exposure device. The RSO for Midwest Industrial X-Ray, was dispatched to the site and arrived at 1345 CDT on 10/21. Source retrieval was completed by 1445 CDT. Exposures were checked on all involved, with a maximum exposure of 3 mR. Midwest Industrial X-Ray is performing an analysis to determine the cause of the disconnect and will submit a written report within 30 days. More information from the Minnesota Department of Health is forthcoming."
The following was received from the State of Minnesota via email:
"At approximately 0815 CDT on Friday, 10/21/16, radiographers for Midwest Industrial X-Ray experienced a source disconnect while working on a project for Excel. The project was taking place outside of Waverly, MN, in a rural area. A 34 Ci source (serial number XF2112, model G60) of Ir-192 experienced a disconnect from a SPEC 150 exposure device. The RSO for Midwest Industrial X-Ray, was dispatched to the site and arrived at 1345 CDT on 10/21. Source retrieval was completed by 1445 CDT. Exposures were checked on all involved, with a maximum exposure of 3 mR. Midwest Industrial X-Ray is performing an analysis to determine the cause of the disconnect and will submit a written report within 30 days. More information from the Minnesota Department of Health is forthcoming."
Agreement State
Event Number: 52341
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: NORTHSIDE HOSPITAL
Region: 1
City: ATLANTA State: GA
County:
License #: GA 39-1. AMEN
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: JOHN SHOEMAKER
Licensee: NORTHSIDE HOSPITAL
Region: 1
City: ATLANTA State: GA
County:
License #: GA 39-1. AMEN
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/02/2016
Notification Time: 11:38 [ET]
Event Date: 10/21/2016
Event Time: 00:00 [EDT]
Last Update Date: 11/02/2016
Notification Time: 11:38 [ET]
Event Date: 10/21/2016
Event Time: 00:00 [EDT]
Last Update Date: 11/02/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION TO INCORRECT SITE
The following report was received from the State of Georgia via email:
"Northside Hospital's Radiation Safety Officer called the Department [Georgia Radioactive Materials Program Environmental Protection Division] on 10/21/2016, informing us of a misadministration with the HDR [High Dose Rate] that occurred approximately two weeks ago. The patient was to receive 5 vaginal treatments consisting of 1 cylinder, 1 capri and 3 capris. The misadministration occurred during the second treatment. The capri was inserted into the rectum instead of the vagina. The Authorized User (AU) was not certain if a misadministration occurred until 2 weeks after the treatment. The AU requested the assistance of the radiologist who confirmed that the rectum was treated instead of the vaginal area. Based on the calculations, the rectum received approximately 350 cGy, what is to be considered a low dose. Additional information from the licensee will be forthcoming."
Treatment material used: Varian Medical Systems, model: Gamma Medplus iX, with an Ir-192 source of less than 22 Ci.
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:
"Northside Hospital's Radiation Safety Officer called the Department [Georgia Radioactive Materials Program Environmental Protection Division] on 10/21/2016, informing us of a misadministration with the HDR [High Dose Rate] that occurred approximately two weeks ago. The patient was to receive 5 vaginal treatments consisting of 1 cylinder, 1 capri and 3 capris. The misadministration occurred during the second treatment. The capri was inserted into the rectum instead of the vagina. The Authorized User (AU) was not certain if a misadministration occurred until 2 weeks after the treatment. The AU requested the assistance of the radiologist who confirmed that the rectum was treated instead of the vaginal area. Based on the calculations, the rectum received approximately 350 cGy, what is to be considered a low dose. Additional information from the licensee will be forthcoming."
Treatment material used: Varian Medical Systems, model: Gamma Medplus iX, with an Ir-192 source of less than 22 Ci.
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.