Event Notification Report for March 11, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/10/2020 - 03/11/2020
Agreement State
Event Number: 54581
Rep Org: SC DEPT OF HEALTH & ENV CONTROL
Licensee: ECS SOUTHEAST, LLP
Region: 1
City: LITTLE RIVER State: SC
County:
License #: 958
Agreement: Y
Docket:
NRC Notified By: JIM PETERSON
HQ OPS Officer: BRIAN LIN
Licensee: ECS SOUTHEAST, LLP
Region: 1
City: LITTLE RIVER State: SC
County:
License #: 958
Agreement: Y
Docket:
NRC Notified By: JIM PETERSON
HQ OPS Officer: BRIAN LIN
Notification Date: 03/11/2020
Notification Time: 11:48 [ET]
Event Date: 03/11/2020
Event Time: 08:15 [EDT]
Last Update Date: 03/11/2020
Notification Time: 11:48 [ET]
Event Date: 03/11/2020
Event Time: 08:15 [EDT]
Last Update Date: 03/11/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATRICK FINNEY (R1DO)
ILTAB (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICK FINNEY (R1DO)
ILTAB (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - STOLEN GAUGE
The following information was received from the state of South Carolina via email:
"On March 11, 2020, the Department [South Carolina Department of Health and Environmental Control (SCDHEC)] was notified by the licensee at approximately 0815 [EDT] that a portable gauging device had been stolen from the licensee's storage location at 19 Highway 90 East, Little River. The gauging device is an Instrotek Model 3500 [moisture density gauge], serial number 722. This device contains 10 milliCuries of Cs-137 and 40 milliCuries of Am-241:Be. The licensee stated that the theft has been reported to local law enforcement. SCDHEC has notified the South Carolina Law Enforcement Division's Fusion Center."
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 information was received from the state of South Carolina via email:
"On March 11, 2020, the Department [South Carolina Department of Health and Environmental Control (SCDHEC)] was notified by the licensee at approximately 0815 [EDT] that a portable gauging device had been stolen from the licensee's storage location at 19 Highway 90 East, Little River. The gauging device is an Instrotek Model 3500 [moisture density gauge], serial number 722. This device contains 10 milliCuries of Cs-137 and 40 milliCuries of Am-241:Be. The licensee stated that the theft has been reported to local law enforcement. SCDHEC has notified the South Carolina Law Enforcement Division's Fusion Center."
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
Event Number: 55208
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: The Regents of the University of California, UC Davis
Region: 4
City: Sacramento State: CA
County:
License #: 1334-57
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Brian P. Smith
Licensee: The Regents of the University of California, UC Davis
Region: 4
City: Sacramento State: CA
County:
License #: 1334-57
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Brian P. Smith
Notification Date: 04/22/2021
Notification Time: 20:45 [ET]
Event Date: 03/11/2020
Event Time: 00:00 [PDT]
Last Update Date: 04/22/2021
Notification Time: 20:45 [ET]
Event Date: 03/11/2020
Event Time: 00:00 [PDT]
Last Update Date: 04/22/2021
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)
EN Revision Imported Date: 5/21/2021
EN Revision Text: AGREEMENT STATE - PATIENT UNDERDOSE
The following report was received via e-mail from the California Department of Public Health - Radiation Health Branch [CDPH-RHB]:
"On March 13, 2020, the licensee radiation safety officer (RSO) contacted CDPH-RHB to report a medical event which occurred on March 11, 2020, and was discovered on March 13, 2020. The licensee reported that a patient was prescribed 200 mCi of I-131 NaI for the treatment of thyroid cancer, but received only 60 mCi on the day of therapy (March 11, 2020). The 200 mCi dose was divided into two capsules and the patient was unintentionally only provided one of the two capsules in a medicine cup by the authorized user. The second capsule was reportedly stuck in the shipping vial which the authorized user thought he had emptied. The 140 mCi I-131 capsule was returned to the radiopharmacy in the shipping vial and pig. This error was discovered when the radiopharmacy contacted the licensee on March 13, 2020 to inform them of the capsule's presence in the returned vial. The Medical Director of Nuclear Medicine was immediately notified, who in turn, notified the RSO. The referring physician was also notified on March 13, 2020 and took responsibility for notifying the patient. A subsequent dosage was administered to complete the therapeutic treatment.
"This medical event was initially reported to CDPH-RHB by telephone on March 13, 2020 and by written report dated March 27, 2020. However, CDPH-RHB does not believe that the medical event was reported to the NRC at that time. A recent inspection by CDPH-RHB brought this medical event to their current attention."
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.
EN Revision Text: AGREEMENT STATE - PATIENT UNDERDOSE
The following report was received via e-mail from the California Department of Public Health - Radiation Health Branch [CDPH-RHB]:
"On March 13, 2020, the licensee radiation safety officer (RSO) contacted CDPH-RHB to report a medical event which occurred on March 11, 2020, and was discovered on March 13, 2020. The licensee reported that a patient was prescribed 200 mCi of I-131 NaI for the treatment of thyroid cancer, but received only 60 mCi on the day of therapy (March 11, 2020). The 200 mCi dose was divided into two capsules and the patient was unintentionally only provided one of the two capsules in a medicine cup by the authorized user. The second capsule was reportedly stuck in the shipping vial which the authorized user thought he had emptied. The 140 mCi I-131 capsule was returned to the radiopharmacy in the shipping vial and pig. This error was discovered when the radiopharmacy contacted the licensee on March 13, 2020 to inform them of the capsule's presence in the returned vial. The Medical Director of Nuclear Medicine was immediately notified, who in turn, notified the RSO. The referring physician was also notified on March 13, 2020 and took responsibility for notifying the patient. A subsequent dosage was administered to complete the therapeutic treatment.
"This medical event was initially reported to CDPH-RHB by telephone on March 13, 2020 and by written report dated March 27, 2020. However, CDPH-RHB does not believe that the medical event was reported to the NRC at that time. A recent inspection by CDPH-RHB brought this medical event to their current attention."
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: 55986
Rep Org: Alabama Radiation Control
Licensee: Wiregrass Medical Center
Region: 1
City: Geneva State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Brian Lin
Licensee: Wiregrass Medical Center
Region: 1
City: Geneva State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 17:56 [ET]
Event Date: 03/11/2020
Event Time: 00:00 [CDT]
Last Update Date: 09/02/2022
Notification Time: 17:56 [ET]
Event Date: 03/11/2020
Event Time: 00:00 [CDT]
Last Update Date: 09/02/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Arner, Frank (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
Arner, Frank (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
EN Revision Imported Date: 9/6/2022
EN Revision Text: AGREEMENT STATE REPORT - DOSE MISADMINISTRATION
The following information was received from the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:
"Issue discovered 6/30/2022, during inspection. The licensee did not report to the Agency at the time of occurrence. The dose to patient was evaluated as a result of a wrong dose on 7/8/2022. [On 3/11/2020,] the patient was prescribed 15 mCi of Tc-99m sestamibi/Cardiolite; the patient received 24.28 mCi of Tc-99m MDP [methyl diphosphonate]. The licensee reported that the nuclear medicine technician did not adequately verify dose labeling, and has been retrained in procedures. [This] appears to result in an effective dose of 512.068 mrem, and dose to bone surfaces of 5659.668 mrem."
AL incident no.: 22-10
* * * UPDATE ON 9/01/2022 AT 1634 EDT FROM ALABAMA OFFICE OF RADIATION CONTROL TO KAREN COTTON * * *
"Cause and Corrective Actions (States and licensees' actions) Licensee reported that the nuclear medicine tech was advised to double check dose labels prior to patient dosing. Licensee also stated personnel were unaware of misadministration reporting requirements (misadministration found during Agency inspection). Event closed"
Notified NMSS DAY (Rivera-Cappella) and R1DO (Gray) and via email: NMSS Event Notification
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.
EN Revision Text: AGREEMENT STATE REPORT - DOSE MISADMINISTRATION
The following information was received from the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:
"Issue discovered 6/30/2022, during inspection. The licensee did not report to the Agency at the time of occurrence. The dose to patient was evaluated as a result of a wrong dose on 7/8/2022. [On 3/11/2020,] the patient was prescribed 15 mCi of Tc-99m sestamibi/Cardiolite; the patient received 24.28 mCi of Tc-99m MDP [methyl diphosphonate]. The licensee reported that the nuclear medicine technician did not adequately verify dose labeling, and has been retrained in procedures. [This] appears to result in an effective dose of 512.068 mrem, and dose to bone surfaces of 5659.668 mrem."
AL incident no.: 22-10
* * * UPDATE ON 9/01/2022 AT 1634 EDT FROM ALABAMA OFFICE OF RADIATION CONTROL TO KAREN COTTON * * *
"Cause and Corrective Actions (States and licensees' actions) Licensee reported that the nuclear medicine tech was advised to double check dose labels prior to patient dosing. Licensee also stated personnel were unaware of misadministration reporting requirements (misadministration found during Agency inspection). Event closed"
Notified NMSS DAY (Rivera-Cappella) and R1DO (Gray) and via email: NMSS Event Notification
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.