Event Notification Report for March 27, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/26/2020 - 03/27/2020
Agreement State
Event Number: 54623
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: CHI ST LUKES HEALTH BAYLOR COLLEGE OF MEDICINE
Region: 4
City: HOUSTON State: TX
County:
License #: L06661
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: BRIAN P. SMITH
Licensee: CHI ST LUKES HEALTH BAYLOR COLLEGE OF MEDICINE
Region: 4
City: HOUSTON State: TX
County:
License #: L06661
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: BRIAN P. SMITH
Notification Date: 03/27/2020
Notification Time: 20:22 [ET]
Event Date: 03/27/2020
Event Time: 00:00 [CDT]
Last Update Date: 03/27/2020
Notification Time: 20:22 [ET]
Event Date: 03/27/2020
Event Time: 00:00 [CDT]
Last Update Date: 03/27/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - UNDERDOSE OF PATIENT MEDICAL EVENT
The following was received from the State of Texas via email:
"On March 27, 2020, the licensee reported that at the completion of a procedure during which 26 milliCuries of Yttrium-90 Sirspheres were administered to a patient, the assay of the tubing, vial, catheter, etc., revealed that the patient had only received approximately 16 milliCuries of the administered dose. Approximately 10 milliCuries were still in the equipment. The authorized user determined this was not the result of vascular stasis. The licensee plans to hold the administration equipment for decay for approximately seven days at which time they will assay and inspect the equipment and attempt to determine the cause. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident Number: 9755
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 was received from the State of Texas via email:
"On March 27, 2020, the licensee reported that at the completion of a procedure during which 26 milliCuries of Yttrium-90 Sirspheres were administered to a patient, the assay of the tubing, vial, catheter, etc., revealed that the patient had only received approximately 16 milliCuries of the administered dose. Approximately 10 milliCuries were still in the equipment. The authorized user determined this was not the result of vascular stasis. The licensee plans to hold the administration equipment for decay for approximately seven days at which time they will assay and inspect the equipment and attempt to determine the cause. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident Number: 9755
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: 54819
Rep Org: VT OFFICE OF RADIOLOGICAL HEALTH
Licensee: Goodenough Rubbish Removal
Region: 1
City: Brattleboro State: VT
County:
License #: N/A
Agreement: Y
Docket:
NRC Notified By: Francis O'Neill
HQ OPS Officer: Rodney Clagg
Licensee: Goodenough Rubbish Removal
Region: 1
City: Brattleboro State: VT
County:
License #: N/A
Agreement: Y
Docket:
NRC Notified By: Francis O'Neill
HQ OPS Officer: Rodney Clagg
Notification Date: 08/06/2020
Notification Time: 10:33 [ET]
Event Date: 03/27/2020
Event Time: 00:00 [EDT]
Last Update Date: 08/06/2020
Notification Time: 10:33 [ET]
Event Date: 03/27/2020
Event Time: 00:00 [EDT]
Last Update Date: 08/06/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - RADIOACTIVE MATERIAL REJECTED AT WASTE FACILITY
The following is a summary of information received via email:
On 3/27/20, the Vermont Department of Health (VDH) was notified that a waste transport truck was rejected at a waste facility in Concord, NH. The truck was rejected because radioactive material was detected in the waste. The truck was redirected to Goodenough Rubbish Removal in Brattleboro, VT, and instructed to isolate the waste.
On 3/30/20, VDH Radiation Control responded to the waste center. The radioactive waste was identified as clay cat litter containing I-131 with a maximum dose rate of 8.04 mrem/hr on contact and 0.54 mrem/hr at one meter while background measurements were 10 microR/hr. The waste hauler was instructed to isolate the container in a remote section of the recycling center with the contents covered for 80 days.
On 4/3/20, VDH issued Vermont Information Notice IN 20-001 (Release of humans and animals receiving I-131 therapy) to all Vermont radioactive materials licensees who are authorized to use I-131. This Information Notice recommends all affected licensees review their I-131 administration procedures, patient release criteria, and pet owner release instructions.
On 6/26/20, a VDH inspector returned to survey the material, and found that the radiation levels of the material were indistinguishable from background.
With the decay of the I-131 waste this incident has been closed out by VDH on 8/5/20.
Vermont Incident No.: VT-20-002
The following is a summary of information received via email:
On 3/27/20, the Vermont Department of Health (VDH) was notified that a waste transport truck was rejected at a waste facility in Concord, NH. The truck was rejected because radioactive material was detected in the waste. The truck was redirected to Goodenough Rubbish Removal in Brattleboro, VT, and instructed to isolate the waste.
On 3/30/20, VDH Radiation Control responded to the waste center. The radioactive waste was identified as clay cat litter containing I-131 with a maximum dose rate of 8.04 mrem/hr on contact and 0.54 mrem/hr at one meter while background measurements were 10 microR/hr. The waste hauler was instructed to isolate the container in a remote section of the recycling center with the contents covered for 80 days.
On 4/3/20, VDH issued Vermont Information Notice IN 20-001 (Release of humans and animals receiving I-131 therapy) to all Vermont radioactive materials licensees who are authorized to use I-131. This Information Notice recommends all affected licensees review their I-131 administration procedures, patient release criteria, and pet owner release instructions.
On 6/26/20, a VDH inspector returned to survey the material, and found that the radiation levels of the material were indistinguishable from background.
With the decay of the I-131 waste this incident has been closed out by VDH on 8/5/20.
Vermont Incident No.: VT-20-002