Event Notification Report for August 05, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/04/2020 - 08/05/2020
Non-Agreement State
Event Number: 54822
Rep Org: Department of Veterans Affairs
Licensee: Department of Veterans Affairs
Region: 4
City: North Little Rock State: AR
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: Kim Wiebeck
HQ OPS Officer: Andrew Waugh
Licensee: Department of Veterans Affairs
Region: 4
City: North Little Rock State: AR
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: Kim Wiebeck
HQ OPS Officer: Andrew Waugh
Notification Date: 08/06/2020
Notification Time: 16:32 [ET]
Event Date: 08/05/2020
Event Time: 13:00 [CDT]
Last Update Date: 08/06/2020
Notification Time: 16:32 [ET]
Event Date: 08/05/2020
Event Time: 13:00 [CDT]
Last Update Date: 08/06/2020
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(3) - Dose To Other Site > Specified Limits
10 CFR Section:
35.3045(a)(3) - Dose To Other Site > Specified Limits
Person (Organization):
KENNETH RIEMER (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
KENNETH RIEMER (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MEDICAL EVENT
"A Y-90 microsphere therapy administration was performed on August 5, 2020, [at VA Boston Healthcare System in Boston, Massachusetts]. The prescribed dose was intended for the right lobe of the liver. Post implant imaging on that day indicated that the dosage of microspheres was unintentionally administered to a portion of the left lobe of the liver.
"The patient and the referring physician have been notified.
"The National Health Physics Program (NHPP) will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045.
"NHPP notified our NRC Region III Project Manager (Parker)."
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.
"A Y-90 microsphere therapy administration was performed on August 5, 2020, [at VA Boston Healthcare System in Boston, Massachusetts]. The prescribed dose was intended for the right lobe of the liver. Post implant imaging on that day indicated that the dosage of microspheres was unintentionally administered to a portion of the left lobe of the liver.
"The patient and the referring physician have been notified.
"The National Health Physics Program (NHPP) will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045.
"NHPP notified our NRC Region III Project Manager (Parker)."
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: 54838
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: InviCRO, LLC
Region: 1
City: Boston State: MA
County:
License #: 55-0692
Agreement: Y
Docket:
NRC Notified By: Tony Carpenito
HQ OPS Officer: Kerby Scales
Licensee: InviCRO, LLC
Region: 1
City: Boston State: MA
County:
License #: 55-0692
Agreement: Y
Docket:
NRC Notified By: Tony Carpenito
HQ OPS Officer: Kerby Scales
Notification Date: 08/14/2020
Notification Time: 17:03 [ET]
Event Date: 08/05/2020
Event Time: 10:20 [EDT]
Last Update Date: 08/14/2020
Notification Time: 17:03 [ET]
Event Date: 08/05/2020
Event Time: 10:20 [EDT]
Last Update Date: 08/14/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - RAM PACKAGES SWITCHED IN ERROR
The following email was received from the Massachusetts Radiation Control Program (the agency) via email:
"On August 5, 2020, InviCRO reported receiving in error on same day a White I package of 140 mCi Lu-177. Receipt survey recorded a package surface dose rate of 0.2 mRem/hr. The received package activity exceeded their license radioactive material possession limit of 125 mCi. Package held by licensee in secure storage until activity falls below license limit (Lu-177 half-life is 6.7 days). The intended activity as requested by the licensee was 60 mCi. Package ordered through Radiomedix in Texas who forwarded order to supplier (ITM Medical isotopes GmbH) in Germany. Package sent from Germany arrived in [common carrier] US facility and directly forwarded to customer without going through Texas. Agency contacted [common carrier] and Texas Department of State Health Services. Apparent cause was [common carrier] accidentally switching labels/paperwork on two similar Lu-177 packages. The package originally intended for InviCRO was forwarded to a customer licensed in Indiana. Indiana customer (Endocyte) notified by Radiomedix. All US parties identified above are aware of incident. Radiomedix continuing its internal investigation. Agency left detailed voicemail messages (including circumstances, package receipt date and activity) at Indiana Department of Homeland Security and Indiana Department of Health. Agency determined this to be a 30-day reportable event and considers this event currently still open."
MA Event Number: 20-4230
The following email was received from the Massachusetts Radiation Control Program (the agency) via email:
"On August 5, 2020, InviCRO reported receiving in error on same day a White I package of 140 mCi Lu-177. Receipt survey recorded a package surface dose rate of 0.2 mRem/hr. The received package activity exceeded their license radioactive material possession limit of 125 mCi. Package held by licensee in secure storage until activity falls below license limit (Lu-177 half-life is 6.7 days). The intended activity as requested by the licensee was 60 mCi. Package ordered through Radiomedix in Texas who forwarded order to supplier (ITM Medical isotopes GmbH) in Germany. Package sent from Germany arrived in [common carrier] US facility and directly forwarded to customer without going through Texas. Agency contacted [common carrier] and Texas Department of State Health Services. Apparent cause was [common carrier] accidentally switching labels/paperwork on two similar Lu-177 packages. The package originally intended for InviCRO was forwarded to a customer licensed in Indiana. Indiana customer (Endocyte) notified by Radiomedix. All US parties identified above are aware of incident. Radiomedix continuing its internal investigation. Agency left detailed voicemail messages (including circumstances, package receipt date and activity) at Indiana Department of Homeland Security and Indiana Department of Health. Agency determined this to be a 30-day reportable event and considers this event currently still open."
MA Event Number: 20-4230