Event Notification Report for August 04, 1999

AGREEMENT STATE REPORT OF A MEDICAL MISADMINISTRATION AT HERMANN HOSPITAL IN HOUSTON, TEXAS (ABNORMAL OCCURRENCE)

The following text is a portion of a facsimile received from the Texas Department of Health Bureau of Radiation Control:

"Incident 7492 - Texas Licensee 650 - Texas is investigating. [Abnormal Occurrence] criteria applies."

"INITIAL NOTIFICATION OF THERAPY MISADMINISTRATION: License L00650"

"Hermann Hospital herewith notifies the Agency of a Misadministration of Radioactive Materials in a therapy procedure."

"Specifically, approximately 27.3 mCi of I-131 was administered to the wrong patient at approximately 1040 a.m. [CDT] on August 4, 1999. The error was discovered at 1315 [CDT] on August 4, 1999."

"The patients involved were both outpatients, female Oriental's, with English as a secondary language. Patient One (for whom the therapy was intended) is approximately 55 years old, while Patient Two (who received the dose inadvertently) is approximately 64 years old."

"Patient Two had completed a scheduled bone density scan and [was] still in the Nuclear Medicine area. At that time, she was mis-identified by the technologist who was to administer the I-131 dose. Patient One was later discovered in the waiting area still needing to be dosed. She later received the prescribed I-131 dose and returned home."

"The nuclear medicine physicians conferred with the Patient Two's personal care physician and with Hermann Hospital's Risk Management Office. The patient was finally located at about 1600 [CDT] on August 4, 1999. The Chief Nuclear Medicine Physician, the Nuclear Pharmacy Manager and the Radiation Safety Officer proceeded to Patient Two's Home and discussed the event with her and her husband. With their consent, we initiated the administration of supersaturated Potassium Iodide (1 ml three times per day) and Furosemide (Lasix) at an initial dosage of 40 mg/day at approximately 1720 [CDT] on August 4, 1999."

"We are, of course, continuing our assessment of the events leading up to this misadministration and will prepare the reports required by TAC 289.252(f)(4)."

(Call the NRC operations officer for state and licensee contact information.)

AGREEMENT STATE REPORT INVOLVING RAD LEVEL EXCEEDING STATE LEVELS DURING SHIPMENT

"This notification is being sent to you per instructions in the NRC Event Reporting Handbook. This event does not pose a threat to public health and safety but is reportable under 1200-2-5-.16(2)(d) of SRPAR. This incident occurred on August 4, 1999. Please see the attached report for details involving this event.

"This letter is sent concerning the American Ecology Recycle Center d/b/a U.S. Ecology Nuclear Materials Management Center (NMMC) Radioactive Material License R-01037-B04. The NMMC is providing written documentation of the reportable event that was reported to your office via telecom on August 6, 1999. The event involved receipt of a radioactive material shipment with external radiation levels in excess of those reportable under State Regulations for Protection Against Radiation (SRPAR) Section 1200-2-5-.16(2)(d).

"Investigation:

"The subject event involved the U.S. Ecology Brokerage division truck and driver on-loading a shipment consisting of a source drum at CTL Engineering, Columbus, OH. Receipt surveys performed at the NMMC denoted an on-contact reading of 450 mR per hour (i.e., greater than the reportable 200 mR per hour) at a single point on the bottom of the truck. The location of the reportable radiation level was not such that it would provide a credible exposure opportunity for a member of the public.

"After on-loading the subject source drum, the truck made eight more stops throughout the mid-west (i.e., OH, MI, IL, IN) over a period of 7 days, with each stop ranging in duration between approximately ½ hour and 4 hours per stop. Interviews with the driver indicate that each stop was in an industrial location with no notable personnel activity (i.e., occupancy) around the truck. The driver also noted that he makes a conscious effort to park away from others when making nightly stops. Therefore, he did not note any personnel activity around his truck that could have led to a credible exposure opportunity for a member of the public.

"Safety Significance:

"There is no plausible scenario in which a member of the public was over-exposed due to this event, The driver, who was the maximally exposed individual, was issued DOSIMETRY of record at the time of the event. His record dose will be evaluated upon the subject TLD being processed.

"Cause:

"The most plausible cause for the event was that the driver made a human performance error while reading his survey meter. Contributing causes to this error were: (1) the infrequency with which the driver works with material involving higher radiation levels and (2) the infrequency with which the driver's radiological skills training is reinforced.

"Corrective Actions:

"The source drum was properly handled upon receipt at the NMMC.

"The driver's radiological skills were upgraded through training.

"The driver will receive periodic radiological skills evaluations as needed to maintain the adequate level of proficiency.

"Safety Significance:

"There is no plausible scenario in which a member of the public was over-exposed due to this event. The driver, who was the maximally exposed individual, was issued dosimetry of record. His record dose will be evaluated upon the subject TLD being processed."

(Call the NRC operations officer for contact telephone numbers.)