Event Notification Report for July 01, 2019

AGREEMENT STATE REPORT - LEAKING SOURCE

The following was received from the state of Wisconsin via email:

"On July 3, 2019, the Department [Wisconsin Radiation Protection Section] received a letter sent and dated July 1, 2019, from GE Healthcare of a source that was discovered to be broken and leaking following it being dropped at the licensee's facility.

"The source (Sanders Medical Products, Germanium-68 Model PET-273/10 sealed source) was being transported in an open-topped lead shield on a cart within the licensee's restricted facility. While moving the cart, an employee lost their grip and the shield fell to the floor. The employee identified that a portion of the source had broken off.

"Using remote handling tongs, the broken portion was returned back into the shield. Surveys were immediately performed, and no contamination was identified on the floor or the employee's hands.

"Follow-up wipe tests were performed on the floor and the source. The source had removable contamination of 220 Bq. The source has been withdrawn from use and secured at the licensee's facility pending disposal.

"The licensee will be performing a review of the incident and their response procedures. A follow-up inspection will be performed by the Department."

Wisconsin Event Report ID No.: WI 190007

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following was received via email:

"On 7/2/2019, the Ohio Department of Health received a phone call from Nationwide Children's Hospital reporting a medical event. The licensee was treating acute myeloid leukemia (AML) with I-131 Iomab using a delivery system that is currently under research and development. The licensee stated the delivery system does not allow the dose vial to be seen and requires the manufacturer to set the infusion time. After the infusion, the technicians discovered the delivery system did not deliver the entire dose to the patient, resulting in an underdose of 42 percent.

"The patient and referring physician have been notified.

"An investigation of the event is pending."

Ohio Item Number: OH190010

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 REPORT - MEDICAL EVENT

The following was received from the state of Illinois via email:

"The Agency [Illinois Bureau of Radiation Safety] was notified at approximately 1530 CDT on 7/1/19, that a medical event had occurred at Alexian Brothers Medical Center, in Elk Grove Village. The circumstances are near identical to those in an event reported by the licensee in February of this year (EN53859). An attempted intravascular brachytherapy procedure utilizing a Novoste BetaCath 3.5F System was aborted when the source train could not successfully reach the intended treatment site after three attempts. The source train was retracted without complication and there were no indications of kinks in the delivery catheter. Aborting the procedure resulted in an underdose exceeding 20 percent of the prescribed dose (prescribed dose was 18.4 Gy of Y-90 and delivered dose was 0.0 Gy). The three attempts also resulted in an exposure exceeding 50 rem to tissue other than the treatment site (treatment site was in the circumflex artery). The source train stopped each of three times 10mm proximal to the treatment site in the junction between the left coronary artery and the circumflex artery. The inadvertently exposed region received approximately 0.98 Gy or a dose equivalent of approximately 100 rem.

"A reactionary inspection was conducted by Agency staff on the morning of July 2, 2019. A written report was received by the licensee that same day in which tortuous patient anatomy was identified as the root cause. Agency inspectors will meet with the authorized user on the afternoon of July 3, 2019, to discuss each step of the intravascular brachytherapy procedure in an effort to further isolate the root cause. No adverse medical impact is expected to the patient as a result of this event, per the authorized user. Patient has been notified and referring physician was present. This report will be updated as additional information becomes available."

Illinois Item Number: IL190016


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-POWER REACTOR REPORT - TECHNICAL SPECIFICATION DEVIATION

The following was received via e-mail:

"On July 1, 2019, sometime between 1100 and 1200 CDT with the reactor shut down and during performance of electrical preventative maintenance, the University of Missouri-Columbia Research Reactor (MURR) deviated from Technical Specification (TS) 3.4 because reactor containment integrity did not exist for approximately ten (10) minutes while the reactor was not secured, as defined by TS 1.26.

"During this event time, two (2) shim control rod drive mechanisms were not installed because scheduled work was in progress on these drive mechanisms. Therefore, the reactor was not secured per TS definition 1.26, but the reactor was shut down per TS definition 1.27. Also during this time, and unknown to the Control Room operators, an Electronics Technician opened the two (2) electrical motor breakers to the reactor containment system's two (2) automatically-closing doors one at a time for approximately 5 minutes each.

"Though this event happened on July 1, no NRC-licensed operator knew that the automatically-closing door motor breakers had been opened on July 1 until mid-day on July 3. Once the abnormal occurrence was realized, the Reactor Facility Director was briefed on the situation on the afternoon of July 3, and he gave permission to continue reactor operation in accordance with TS 6.6.c.(4).

"This email is a required notification per TS 6.6.c.(1) to report to the NRC Operations Center that an Abnormal Occurrence, as defined by TS 1.1.b, has occurred. MURR was not in compliance with all of the Limiting Conditions for Operations as established in TS Section 3.0.

"A detailed event report will follow within 14 days as required by TS 6.6.c.(3)."

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following was received from the State of Colorado via email:

One tritium exit sign, containing 6.2 Curies, was determined to be lost after not being found on the property by new management.

Initial Date Reported: 7/1/2019

Final Decision Material Lost Date: 7/1/2019

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

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following was received from the state of Colorado via email:

"One tritium exit sign, containing 6.2 Curies, was determined lost after it was removed during renovation.

"Initial Date Reported: 7/1/19

"Final Decision Material Lost Date: 7/1/19"

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

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following information was received via email:

The licensee is unable to locate six tritium exit signs that have an activity of 7.5 Ci each. The exit signs may have been lost during a renovation.

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