Event Notification Report for May 09, 2018
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/08/2018 - 05/09/2018
Agreement State
Event Number: 54619
Rep Org: COLORADO DEPT OF HEALTH
Licensee: CHERRY HILLS CONDO CORPORATION III
Region: 4
City: DENVER State: CO
County:
License #: GL002177
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: CATY NOLAN
Licensee: CHERRY HILLS CONDO CORPORATION III
Region: 4
City: DENVER State: CO
County:
License #: GL002177
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: CATY NOLAN
Notification Date: 03/26/2020
Notification Time: 15:29 [ET]
Event Date: 05/09/2018
Event Time: 00:00 [MDT]
Last Update Date: 03/26/2020
Notification Time: 15:29 [ET]
Event Date: 05/09/2018
Event Time: 00:00 [MDT]
Last Update Date: 03/26/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
LAURA PEARSON (ILTAB)
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
LAURA PEARSON (ILTAB)
AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS
The following was received from the state of Colorado via email:
"Two tritium exit signs, containing 6.0 Curies each, was determined lost after a change in management.
"Initial Date Reported: 12/18/17
"Final Decision Material Lost Date: 5/9/18"
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 was received from the state of Colorado via email:
"Two tritium exit signs, containing 6.0 Curies each, was determined lost after a change in management.
"Initial Date Reported: 12/18/17
"Final Decision Material Lost Date: 5/9/18"
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
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State
Event Number: 53450
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: WESTERN TUMOR MEDICAL GROUP
Region: 4
City: LOS ANGELES State: CA
County: LOS ANGELES
License #: 7954-19
Agreement: Y
Docket:
NRC Notified By: THOMAS GEZA MIKO
HQ OPS Officer: THOMAS KENDZIA
Licensee: WESTERN TUMOR MEDICAL GROUP
Region: 4
City: LOS ANGELES State: CA
County: LOS ANGELES
License #: 7954-19
Agreement: Y
Docket:
NRC Notified By: THOMAS GEZA MIKO
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 06/09/2018
Notification Time: 10:48 [ET]
Event Date: 05/09/2018
Event Time: 00:00 [PDT]
Last Update Date: 08/14/2018
Notification Time: 10:48 [ET]
Event Date: 05/09/2018
Event Time: 00:00 [PDT]
Last Update Date: 08/14/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - INCORRECT DOSE ADMINISTRATION
The following report was received from the State of California by email:
"[The] National Director Medical Physics, of McKesson Specialty Health, Radiation & Imaging, contacted LA County Radiation Management (LA County) on June 8, 2018 to report a potential Medical Event that occurred at Western Tumor Medical Group on May 9, 2018. The National Director Medical Physics has been remotely reviewing available data at their location in Decatur, Georgia, and while they are not able to definitively conclude the unplanned dose to the patient's small intestine/bowel pending the return of the Western Tumor Medical Group RSO from overseas, it appears that a Medical Event occurred.
"The potential Medical Event occurred during an HDR [High Dose Rate] brachytherapy procedure in which the tandem ovoid insert shifted inside of the female patient's pelvis (which has extensive damage from uterine cancer) apparently causing two of the dwells to shift to a position different from that in the treatment plan. As a result, the dose to the non-target small intestine/bowel from the 1st of 3 fractions is believed to have been about 587 cGy (587 rad), instead of the planned approximately 220 cGy (220 rad). The treatment plan was modified for the shifted tandem ovoid position, and the 2nd and 3rd fractions were given resulting in approximately 220 cGy (220 rad) each to the small intestine/bowel.
"A site visit will be conducted to meet with the licensee's personnel when the RSO comes back from travel to gain a better understanding of the details of the event, including the delay in the reporting of the event by the RSO, and patient/patient's physician notification."
* * * RETRACTION FROM THOMAS GEZA TO VINCE KLCO ON 8/14/18 AT 1425 EDT * * *
The following information was received from the State of California via email:
"Calculations have been performed by the Licensee's RSO that demonstrated to [the State of California] that [the dosage] fell below the reportability threshold of 10 CFR 35.3045(a)(1) and 35.3045(a)(3) because the dose occurred to the non-target organ, and only in the first of the 3 fractions, causing the numbers to even out, i.e., average down to below reportable numbers (in terms of 50 REM and 50% of planned dose)."
California ID # 060818
Notified the R4DO (Deese) and NMSS Events Notifications via email.
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 California by email:
"[The] National Director Medical Physics, of McKesson Specialty Health, Radiation & Imaging, contacted LA County Radiation Management (LA County) on June 8, 2018 to report a potential Medical Event that occurred at Western Tumor Medical Group on May 9, 2018. The National Director Medical Physics has been remotely reviewing available data at their location in Decatur, Georgia, and while they are not able to definitively conclude the unplanned dose to the patient's small intestine/bowel pending the return of the Western Tumor Medical Group RSO from overseas, it appears that a Medical Event occurred.
"The potential Medical Event occurred during an HDR [High Dose Rate] brachytherapy procedure in which the tandem ovoid insert shifted inside of the female patient's pelvis (which has extensive damage from uterine cancer) apparently causing two of the dwells to shift to a position different from that in the treatment plan. As a result, the dose to the non-target small intestine/bowel from the 1st of 3 fractions is believed to have been about 587 cGy (587 rad), instead of the planned approximately 220 cGy (220 rad). The treatment plan was modified for the shifted tandem ovoid position, and the 2nd and 3rd fractions were given resulting in approximately 220 cGy (220 rad) each to the small intestine/bowel.
"A site visit will be conducted to meet with the licensee's personnel when the RSO comes back from travel to gain a better understanding of the details of the event, including the delay in the reporting of the event by the RSO, and patient/patient's physician notification."
* * * RETRACTION FROM THOMAS GEZA TO VINCE KLCO ON 8/14/18 AT 1425 EDT * * *
The following information was received from the State of California via email:
"Calculations have been performed by the Licensee's RSO that demonstrated to [the State of California] that [the dosage] fell below the reportability threshold of 10 CFR 35.3045(a)(1) and 35.3045(a)(3) because the dose occurred to the non-target organ, and only in the first of the 3 fractions, causing the numbers to even out, i.e., average down to below reportable numbers (in terms of 50 REM and 50% of planned dose)."
California ID # 060818
Notified the R4DO (Deese) and NMSS Events Notifications via email.
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.