Event Notification Report for February 06, 2018
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/05/2018 - 02/06/2018
Non-Agreement State
Event Number: 53200
Rep Org: CENTRO DE RADIOTERAPIA
Licensee: CENTRO DE RADIOTERAPIA
Region: 1
City: Hato Rey State: PR
County:
License #: 52-30937-01
Agreement: N
Docket:
NRC Notified By: LUIS RIVERA
HQ OPS Officer: ANDREW WAUGH
Licensee: CENTRO DE RADIOTERAPIA
Region: 1
City: Hato Rey State: PR
County:
License #: 52-30937-01
Agreement: N
Docket:
NRC Notified By: LUIS RIVERA
HQ OPS Officer: ANDREW WAUGH
Notification Date: 02/08/2018
Notification Time: 14:47 [ET]
Event Date: 02/06/2018
Event Time: 00:00 [EST]
Last Update Date: 02/23/2018
Notification Time: 14:47 [ET]
Event Date: 02/06/2018
Event Time: 00:00 [EST]
Last Update Date: 02/23/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(b) - PATIENT INTERVENTION DAMAGE
10 CFR Section:
35.3045(b) - PATIENT INTERVENTION DAMAGE
Person (Organization):
RAY POWELL (R1DO)
DOUGLAS BOLLOCK (NMSS)
NMSS_EVENTS_NOTIFICA (EMAI)
RAY POWELL (R1DO)
DOUGLAS BOLLOCK (NMSS)
NMSS_EVENTS_NOTIFICA (EMAI)
SKIN REACTION RESULTING FROM RADIATION THERAPY
The following event was received from Auxilio Mutuo Radiation Therapy Center via phone:
A patient who had undergone three gynecological intracavitary brachytherapy procedures was noticed to have a skin reaction. The skin reaction was noticed on the third of the three treatments occurring on 1/24/2018. At this point, it was unclear if the skin reaction was related to the treatments. On 2/6/2018, the attending physician saw the patient and declared that the skin reaction was caused by the radiation treatments, because it had progressed to moist desquamation.
The prescribed dose was 400 cGy per fraction for 3 fractions for a total of 1,200 cGy to a depth of 5 cm.
This event is under further investigation.
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 event was received from Auxilio Mutuo Radiation Therapy Center via phone:
A patient who had undergone three gynecological intracavitary brachytherapy procedures was noticed to have a skin reaction. The skin reaction was noticed on the third of the three treatments occurring on 1/24/2018. At this point, it was unclear if the skin reaction was related to the treatments. On 2/6/2018, the attending physician saw the patient and declared that the skin reaction was caused by the radiation treatments, because it had progressed to moist desquamation.
The prescribed dose was 400 cGy per fraction for 3 fractions for a total of 1,200 cGy to a depth of 5 cm.
This event is under further investigation.
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.
Agreement State
Event Number: 53197
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: PREMIER TESTING AND INSPECTION, INC
Region: 4
City: TEMECULA State: CA
County:
License #: 7988-33
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: DAVID AIRD
Licensee: PREMIER TESTING AND INSPECTION, INC
Region: 4
City: TEMECULA State: CA
County:
License #: 7988-33
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: DAVID AIRD
Notification Date: 02/06/2018
Notification Time: 16:10 [ET]
Event Date: 02/06/2018
Event Time: 08:00 [PST]
Last Update Date: 02/06/2018
Notification Time: 16:10 [ET]
Event Date: 02/06/2018
Event Time: 08:00 [PST]
Last Update Date: 02/06/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)
CNSNS (MEXICO) (EMAI)
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)
CNSNS (MEXICO) (EMAI)
AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE
The following information was received from the State of California via email:
"On February 6, 2018, at approximately 0845 [PST] [the RSO] of Southwest Calibration & Training, Radioactive Materials License #7567-36, contacted RHB [CA Radiologic Health Branch] Brea concerning the moisture/density gauge, CPN, MC1-DRP, serial #MD40507411 (Cs-137 0.375 GBq, Am-241 1.8 GBq) that had been stolen from a transport vehicle [in] Indio, CA at approximately 0800 [PST]. At 0930 [PST], the RSO of Premier Testing & Inspection, Inc., telephoned RHB Brea to inform that the Authorized User had contacted local law enforcement in Indio, [CA] and was filling out a police report with them. A copy of the theft report will be forwarded to the RHB Brea office to be included as part of this report. [The RSO for Premier Testing & Inspection, Inc.] will contact local newspapers to attempt to retrieve the stolen radioactive gauge as well as notifying local servicing vendors of radioactive gauges to be alert for the serial number of the stolen gauge in case it turns up for service. The investigation will continue to determine if the radioactive gauge can be recovered in a reasonable time frame. This is being reported to the NRC Operations Center as a 24-hour report under 10CFR30.50(b)(2) since the radioactive gauge has been stolen and it cannot be determined what condition the sources are currently in."
5010 NUMBER: 020618
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 received from the State of California via email:
"On February 6, 2018, at approximately 0845 [PST] [the RSO] of Southwest Calibration & Training, Radioactive Materials License #7567-36, contacted RHB [CA Radiologic Health Branch] Brea concerning the moisture/density gauge, CPN, MC1-DRP, serial #MD40507411 (Cs-137 0.375 GBq, Am-241 1.8 GBq) that had been stolen from a transport vehicle [in] Indio, CA at approximately 0800 [PST]. At 0930 [PST], the RSO of Premier Testing & Inspection, Inc., telephoned RHB Brea to inform that the Authorized User had contacted local law enforcement in Indio, [CA] and was filling out a police report with them. A copy of the theft report will be forwarded to the RHB Brea office to be included as part of this report. [The RSO for Premier Testing & Inspection, Inc.] will contact local newspapers to attempt to retrieve the stolen radioactive gauge as well as notifying local servicing vendors of radioactive gauges to be alert for the serial number of the stolen gauge in case it turns up for service. The investigation will continue to determine if the radioactive gauge can be recovered in a reasonable time frame. This is being reported to the NRC Operations Center as a 24-hour report under 10CFR30.50(b)(2) since the radioactive gauge has been stolen and it cannot be determined what condition the sources are currently in."
5010 NUMBER: 020618
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