Event Notification Report for October 22, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/21/2019 - 10/22/2019
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State
Event Number: 54344
Rep Org: OZARK MEDICAL CENTER
Licensee: OZARK MEDICAL CENTER
Region: 3
City: WEST PLAINS State: MO
County:
License #: 24-18733-01
Agreement: N
Docket:
NRC Notified By: JOHN MCKENZIE
HQ OPS Officer: OSSY FONT
Licensee: OZARK MEDICAL CENTER
Region: 3
City: WEST PLAINS State: MO
County:
License #: 24-18733-01
Agreement: N
Docket:
NRC Notified By: JOHN MCKENZIE
HQ OPS Officer: OSSY FONT
Notification Date: 10/22/2019
Notification Time: 16:24 [ET]
Event Date: 10/22/2019
Event Time: 13:30 [CDT]
Last Update Date: 10/29/2019
Notification Time: 16:24 [ET]
Event Date: 10/22/2019
Event Time: 13:30 [CDT]
Last Update Date: 10/29/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
KARLA STOEDTER (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
KARLA STOEDTER (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ADMINISTRATION OF DOSE TO WRONG INDIVIDUAL
The following is a synopsis of information received via phone:
On 10/22/19, at approximately 1330 CDT, 22.0 mCi of Tc-99m-white blood cells was administered to the wrong patient. The patient was confused and not able to correctly confirm that they were the patient receiving the dose. This patient was informed of event, but has a power of attorney who will also be notified. This patient's condition means the dose, carried by the white blood cells, will possibly end up in their bowel. Extra monitoring is being performed.
The correct patient will be rescheduled.
* * * RETRACTION ON 10/29/2019 AT 1257 EDT FROM JOHN MCKENZIE TO ANDREW WAUGH * * *
After discussion with R3 (Gattone), Ozark Medical Center is retracting this event because the delivered dose does not exceed the reportable limits described in 10 CFR 35.3045.
Notified R3DO (Riemer) and NMSS Events Notification (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 is a synopsis of information received via phone:
On 10/22/19, at approximately 1330 CDT, 22.0 mCi of Tc-99m-white blood cells was administered to the wrong patient. The patient was confused and not able to correctly confirm that they were the patient receiving the dose. This patient was informed of event, but has a power of attorney who will also be notified. This patient's condition means the dose, carried by the white blood cells, will possibly end up in their bowel. Extra monitoring is being performed.
The correct patient will be rescheduled.
* * * RETRACTION ON 10/29/2019 AT 1257 EDT FROM JOHN MCKENZIE TO ANDREW WAUGH * * *
After discussion with R3 (Gattone), Ozark Medical Center is retracting this event because the delivered dose does not exceed the reportable limits described in 10 CFR 35.3045.
Notified R3DO (Riemer) and NMSS Events Notification (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.
Agreement State
Event Number: 55665
Rep Org: New Mexico Rad Control Program
Licensee: Spectratek
Region: 4
City: Albuquerque State: NM
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Carl M Sullivan
HQ OPS Officer: Thomas Herrity
Licensee: Spectratek
Region: 4
City: Albuquerque State: NM
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Carl M Sullivan
HQ OPS Officer: Thomas Herrity
Notification Date: 12/20/2021
Notification Time: 11:42 [ET]
Event Date: 10/22/2019
Event Time: 00:00 [MST]
Last Update Date: 12/20/2021
Notification Time: 11:42 [ET]
Event Date: 10/22/2019
Event Time: 00:00 [MST]
Last Update Date: 12/20/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
O'Keefe, Neil (R4)
NMSS_Events_Notification, (EMAIL)
Fisher, Jennifer (NMSS DAY)
O'Keefe, Neil (R4)
NMSS_Events_Notification, (EMAIL)
Fisher, Jennifer (NMSS DAY)
EN Revision Imported Date: 1/20/2022
EN Revision Text: AGREEMENT STATE REPORT - CONTAMINATED WORKER
The following is a synopsis of information received from the New Mexico Radiation Control Bureau (NMRCB):
On October 22, 2019, a worker was manually drilling a container with 1080 millicuries of iridium-192 in ceramic tracer beads. The worker was not wearing eye or face shields and a puff of dust from the drilling struck the worker's face and eyes. Immediately after, the worker repeatedly washed their face and eyes. On the next day, a survey of the worker's face/eye area showed 200 mR/hr. Subsequent surveys over the next 103 days showed steadily decreasing amounts, down to 10 mR/hr at 103 days.
On June 23, 2020, the NMRCB reached out to the NRC seeking assistance in determining the individual's dose. Staff from the Office of Nuclear Material Safety and Safeguards (NMSS) and Region IV Division of Nuclear Materials Safety (DNMS) held a call with NMRCB, providing options on how to proceed, including encouraging the individual submit to a full body count. A whole body radiobioassay was performed on July 17, 2020, 272 days after the exposure. The result on the first run was 4.12 nCi and 4.34 nCi on the second run.
A reported dated November 18, 2021, [a contractor] presented results indicating a committed effective dose equivalent (CEDE) to the worker of 1.48 millirem, a shallow dose equivalent (SDE) estimated to be 663 rem, a lens dose equivalent (LDE) estimated to be 11.5 rem, and an effective dose equivalent (EDE) of 3.6 millirem.
EN Revision Text: AGREEMENT STATE REPORT - CONTAMINATED WORKER
The following is a synopsis of information received from the New Mexico Radiation Control Bureau (NMRCB):
On October 22, 2019, a worker was manually drilling a container with 1080 millicuries of iridium-192 in ceramic tracer beads. The worker was not wearing eye or face shields and a puff of dust from the drilling struck the worker's face and eyes. Immediately after, the worker repeatedly washed their face and eyes. On the next day, a survey of the worker's face/eye area showed 200 mR/hr. Subsequent surveys over the next 103 days showed steadily decreasing amounts, down to 10 mR/hr at 103 days.
On June 23, 2020, the NMRCB reached out to the NRC seeking assistance in determining the individual's dose. Staff from the Office of Nuclear Material Safety and Safeguards (NMSS) and Region IV Division of Nuclear Materials Safety (DNMS) held a call with NMRCB, providing options on how to proceed, including encouraging the individual submit to a full body count. A whole body radiobioassay was performed on July 17, 2020, 272 days after the exposure. The result on the first run was 4.12 nCi and 4.34 nCi on the second run.
A reported dated November 18, 2021, [a contractor] presented results indicating a committed effective dose equivalent (CEDE) to the worker of 1.48 millirem, a shallow dose equivalent (SDE) estimated to be 663 rem, a lens dose equivalent (LDE) estimated to be 11.5 rem, and an effective dose equivalent (EDE) of 3.6 millirem.