Event Notification Report for August 09, 2018
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/08/2018 - 08/09/2018
Agreement State
Event Number: 53543
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: INTERNATIONAL PAPER
Region: 1
City: RIEGELWOOD State: NC
County:
License #: 024-0013-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: OSSY FONT
Licensee: INTERNATIONAL PAPER
Region: 1
City: RIEGELWOOD State: NC
County:
License #: 024-0013-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: OSSY FONT
Notification Date: 08/10/2018
Notification Time: 14:29 [ET]
Event Date: 08/09/2018
Event Time: 00:00 [EDT]
Last Update Date: 08/10/2018
Notification Time: 14:29 [ET]
Event Date: 08/09/2018
Event Time: 00:00 [EDT]
Last Update Date: 08/10/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - FAILED GAUGE SHUTTER
The following information was received via email from the State of North Carolina:
"NC RMB (North Carolina Radioactive Materials Branch) was notified by an authorized service provider, Systems Service Corporation (License Number: 090-1071-1), that they had repaired a failed shutter on a fixed nuclear gauge located at International Paper located in Riegelwood, NC on 8/9/18. The shutter detent spring was corroded and dissolved due to its corrosive environment. The service provider removed the gauge and rebuilt it on site with another source housing.
"No known overexposures occurred during this event and it is unknown at this time whether the shutter was in an open or closed position. However, this investigation is still ongoing at the time of this report.
"No other generic implications at this time. No other notifications made.
"Source & Device Information: TBD. This report will be updated once RMB completes its investigation."
North Carolina Report Number: 180034
The following information was received via email from the State of North Carolina:
"NC RMB (North Carolina Radioactive Materials Branch) was notified by an authorized service provider, Systems Service Corporation (License Number: 090-1071-1), that they had repaired a failed shutter on a fixed nuclear gauge located at International Paper located in Riegelwood, NC on 8/9/18. The shutter detent spring was corroded and dissolved due to its corrosive environment. The service provider removed the gauge and rebuilt it on site with another source housing.
"No known overexposures occurred during this event and it is unknown at this time whether the shutter was in an open or closed position. However, this investigation is still ongoing at the time of this report.
"No other generic implications at this time. No other notifications made.
"Source & Device Information: TBD. This report will be updated once RMB completes its investigation."
North Carolina Report Number: 180034
Agreement State
Event Number: 53544
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: OREGON HEALTH & SCIENCE UNIVERSITY
Region: 4
City: PORTLAND State: OR
County:
License #: 90013
Agreement: Y
Docket:
NRC Notified By: HILLARY HASKINS
HQ OPS Officer: OSSY FONT
Licensee: OREGON HEALTH & SCIENCE UNIVERSITY
Region: 4
City: PORTLAND State: OR
County:
License #: 90013
Agreement: Y
Docket:
NRC Notified By: HILLARY HASKINS
HQ OPS Officer: OSSY FONT
Notification Date: 08/10/2018
Notification Time: 17:29 [ET]
Event Date: 08/09/2018
Event Time: 00:00 [PDT]
Last Update Date: 08/10/2018
Notification Time: 17:29 [ET]
Event Date: 08/09/2018
Event Time: 00:00 [PDT]
Last Update Date: 08/10/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MISADMINISTRATION OF Y-90 MICROSPHERES
The following is a summary from a report received via email from the State of Oregon:
On 08/09/18, the Oregon Health & Science University (OHSU) Radiation Safety Officer (RSO) reported a misadministered of Y-90 treatment. The activity was 294 Gy, more than twice what was in the written directive (WD), 136 Gy. The prescribed range was 109-163 Gy.
The normal pre-procedure process, while still in Nuclear Medicine, includes a dose calibrator reading, which was done, and a decay calculation done based on the manufacturer's calibration data sheet. The two were within 10%. The decayed activity result (or calibrator reading) is supposed to be compared with the WD required activity before taking the dose up to Interventional Radiology (IR) for the preadministration measurements.
For this case, the RSO was responsible for the calculation and verification, and should have noticed the incorrect dose before taking it to IR, but the comparison with the WD dose was not done.
Another Y-90 dose had been delivered to Nuclear Medicine that morning to decay prior to a case the next week. This was the dose the Nuclear Medicine tech opened and measured, without checking the printed code on the shipping box, which includes the patient's initials.
Additionally, another check is done by the nurse manager for these cases, who goes down the day before to verify what was received. The packing slip showed a 5 GBq dose, which was correct and it was the right shipping box.
The interventional radiologist was informed as soon as the post-delivery calculations were confirmed. He spoke with the patient, and sent the patient to Nuclear Medicine to be imaged. The scan showed very good containment within the liver. The physician felt the patient actually should tolerate the dose, as he had considered administering a high ablation type of dose (>200 Gy), and because of where the dose was delivered.
Corrective actions included a procedure modification; specifically, a dose verification step will be added when the dose is up in IR during the preliminary set-up with the nurse manager. Other steps will be put in place after further discussion. The event is being entered into the hospital notification system, and likely will receive further review at that level.
The RSO will submit the full report within the required 20 days.
Oregon Item Number: OR180002
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 is a summary from a report received via email from the State of Oregon:
On 08/09/18, the Oregon Health & Science University (OHSU) Radiation Safety Officer (RSO) reported a misadministered of Y-90 treatment. The activity was 294 Gy, more than twice what was in the written directive (WD), 136 Gy. The prescribed range was 109-163 Gy.
The normal pre-procedure process, while still in Nuclear Medicine, includes a dose calibrator reading, which was done, and a decay calculation done based on the manufacturer's calibration data sheet. The two were within 10%. The decayed activity result (or calibrator reading) is supposed to be compared with the WD required activity before taking the dose up to Interventional Radiology (IR) for the preadministration measurements.
For this case, the RSO was responsible for the calculation and verification, and should have noticed the incorrect dose before taking it to IR, but the comparison with the WD dose was not done.
Another Y-90 dose had been delivered to Nuclear Medicine that morning to decay prior to a case the next week. This was the dose the Nuclear Medicine tech opened and measured, without checking the printed code on the shipping box, which includes the patient's initials.
Additionally, another check is done by the nurse manager for these cases, who goes down the day before to verify what was received. The packing slip showed a 5 GBq dose, which was correct and it was the right shipping box.
The interventional radiologist was informed as soon as the post-delivery calculations were confirmed. He spoke with the patient, and sent the patient to Nuclear Medicine to be imaged. The scan showed very good containment within the liver. The physician felt the patient actually should tolerate the dose, as he had considered administering a high ablation type of dose (>200 Gy), and because of where the dose was delivered.
Corrective actions included a procedure modification; specifically, a dose verification step will be added when the dose is up in IR during the preliminary set-up with the nurse manager. Other steps will be put in place after further discussion. The event is being entered into the hospital notification system, and likely will receive further review at that level.
The RSO will submit the full report within the required 20 days.
Oregon Item Number: OR180002
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: 53545
Rep Org: US DEPARTMENT OF VETERANS AFFAIRS
Licensee: US DEPARTMENT OF VETERANS AFFAIRS
Region: 4
City: PORTLAND State: OR
County:
License #:
Agreement: Y
Docket:
NRC Notified By: EDWIN LEIDHOLDT Jr.
HQ OPS Officer: DONALD NORWOOD
Licensee: US DEPARTMENT OF VETERANS AFFAIRS
Region: 4
City: PORTLAND State: OR
County:
License #:
Agreement: Y
Docket:
NRC Notified By: EDWIN LEIDHOLDT Jr.
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/10/2018
Notification Time: 19:36 [ET]
Event Date: 08/09/2018
Event Time: 00:00 [PDT]
Last Update Date: 08/10/2018
Notification Time: 19:36 [ET]
Event Date: 08/09/2018
Event Time: 00:00 [PDT]
Last Update Date: 08/10/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MISADMINISTRATION OF Y-90 MICROSPHERES
"This event occurred on August 9, 2018, at the VA Portland Health Care System, Portland, Oregon.
"The patient was to receive a prescribed dose of 134 gray to a segment of the liver as a treatment for liver cancer, with Y-90 microspheres. After the procedure, the [actual] dose to the intended segment was estimated as approximately 103 gray, 77 percent of the prescribed dose.
"The patient has been notified. No harm to the patient is anticipated."
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.
"This event occurred on August 9, 2018, at the VA Portland Health Care System, Portland, Oregon.
"The patient was to receive a prescribed dose of 134 gray to a segment of the liver as a treatment for liver cancer, with Y-90 microspheres. After the procedure, the [actual] dose to the intended segment was estimated as approximately 103 gray, 77 percent of the prescribed dose.
"The patient has been notified. No harm to the patient is anticipated."
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.