Event Notification Report for June 21, 2018
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/20/2018 - 06/21/2018
Agreement State
Event Number: 53466
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: CHURCH OF JESUS CHRIST OF LATTER-DAY SAINTS
Region: 4
City: EMERY State: UT
County:
License #: NONE
Agreement: Y
Docket:
NRC Notified By: SPENCER WICKHAM
HQ OPS Officer: RICHARD SMITH
Licensee: CHURCH OF JESUS CHRIST OF LATTER-DAY SAINTS
Region: 4
City: EMERY State: UT
County:
License #: NONE
Agreement: Y
Docket:
NRC Notified By: SPENCER WICKHAM
HQ OPS Officer: RICHARD SMITH
Notification Date: 06/21/2018
Notification Time: 18:12 [ET]
Event Date: 06/21/2018
Event Time: 13:35 [MDT]
Last Update Date: 06/21/2018
Notification Time: 18:12 [ET]
Event Date: 06/21/2018
Event Time: 13:35 [MDT]
Last Update Date: 06/21/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - LOST TRITIUM SIGNS
The following was received from the state of Utah via E-mail:
On June 21, 2018 at 1335 MDT, Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (DWMRC), received written notification from the Church of Jesus Christ and Latter-Day Saints that on June 21, 2018 four tritium exit signs were discovered to having been sent to the landfill for disposal. The licensee will continue to investigate the incident and will submit a written report to the DWMRC.
Utah Event Report ID No: UT180004.
The following was received from the state of Utah via E-mail:
On June 21, 2018 at 1335 MDT, Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (DWMRC), received written notification from the Church of Jesus Christ and Latter-Day Saints that on June 21, 2018 four tritium exit signs were discovered to having been sent to the landfill for disposal. The licensee will continue to investigate the incident and will submit a written report to the DWMRC.
Utah Event Report ID No: UT180004.
Agreement State
Event Number: 53468
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: EMORY UNIVERSITY
Region: 1
City: Atlanta State: GA
County:
License #: GA 153-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: THOMAS KENDZIA
Licensee: EMORY UNIVERSITY
Region: 1
City: Atlanta State: GA
County:
License #: GA 153-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 06/22/2018
Notification Time: 14:26 [ET]
Event Date: 06/21/2018
Event Time: 00:00 [EDT]
Last Update Date: 07/02/2018
Notification Time: 14:26 [ET]
Event Date: 06/21/2018
Event Time: 00:00 [EDT]
Last Update Date: 07/02/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ART BURRITT (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DOSE MISADMINISTRATION
The following information was received from the State of Georgia via email;
"RMP [Georgia Radioactive Materials Program] received a call regarding an event that occurred at the main Emory Campus. A 57 year old male was treated on June 21, 2018 with 81.1 mCi of Y-90 Therasphere. The treatment site was the right lobe of the liver. Approximately an hour after the treatment the patient was scanned. The scan indicated that approximately 80% of the administered dose went to the left lobe, 10% went to the right lobe and some went to the stomach and some went to the 1st portion of the duodenum. It was determined there was a vessel spasm during the treatment that caused the theraspheres to shunt to the left lobe of the liver."
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.
Georgia Incident Report # 3.
* * * UPDATE FROM IRENE BENNETT TO VINCE KLCO ON 6/2/2018 AT 1426 EDT * * *
The following information was received from the State of Georgia via email:
"[The Georgia Radioactive Materials Program] received Emory's report regarding the Y-90 procedure and verified the backflow to the left lobe was due to shunting. Based on this information, [Georgia has] determined that this is not a medical event. All documentation will be filed in the licensee's file and electronically."
Notified the R1DO (Powell) and the NMSS Events Group via email.
The following information was received from the State of Georgia via email;
"RMP [Georgia Radioactive Materials Program] received a call regarding an event that occurred at the main Emory Campus. A 57 year old male was treated on June 21, 2018 with 81.1 mCi of Y-90 Therasphere. The treatment site was the right lobe of the liver. Approximately an hour after the treatment the patient was scanned. The scan indicated that approximately 80% of the administered dose went to the left lobe, 10% went to the right lobe and some went to the stomach and some went to the 1st portion of the duodenum. It was determined there was a vessel spasm during the treatment that caused the theraspheres to shunt to the left lobe of the liver."
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.
Georgia Incident Report # 3.
* * * UPDATE FROM IRENE BENNETT TO VINCE KLCO ON 6/2/2018 AT 1426 EDT * * *
The following information was received from the State of Georgia via email:
"[The Georgia Radioactive Materials Program] received Emory's report regarding the Y-90 procedure and verified the backflow to the left lobe was due to shunting. Based on this information, [Georgia has] determined that this is not a medical event. All documentation will be filed in the licensee's file and electronically."
Notified the R1DO (Powell) and the NMSS Events Group via email.