United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated With Events > Event Notification Reports > 2003 > August 6

Event Notification Report for August 6, 2003






                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           08/05/2003 - 08/06/2003



                              ** EVENT NUMBERS **



40042  40047  



+------------------------------------------------------------------------------+

|General Information or Other                     |Event Number:   40042       |

+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+

| REP ORG:  ILLINOIS DEPT OF NUCLEAR SAFETY      |NOTIFICATION DATE: 07/31/2003|

|LICENSEE:  RUSH COPLEY MEDICAL CENTER           |NOTIFICATION TIME: 17:50[EDT]|

|    CITY:  AURORA                   REGION:  3  |EVENT DATE:        07/28/2003|

|  COUNTY:                            STATE:  IL |EVENT TIME:             [CDT]|

|LICENSE#:  IL-01207-01           AGREEMENT:  Y  |LAST UPDATE DATE:  08/01/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |BRUCE BURGESS        R3      |

|                                                |DANIEL GILLEN        NMSS    |

+------------------------------------------------+                             |

| NRC NOTIFIED BY:  JOE KLINGER                  |                             |

|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |

+------------------------------------------------+                             |

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

+------------------------------------------------------------------------------+



                                   EVENT TEXT                                   

+------------------------------------------------------------------------------+

| AGREEMENT STATE REPORT - MEDICAL EVENT                                       |

|                                                                              |

| The following information was received via e-mail from the Illinois          |

| Department of Nuclear Safety:                                                |

|                                                                              |

| "Abstract:                                                                   |

|                                                                              |

| "The agency [Illinois Department of Nuclear Safety] received a call July 29, |

| 2003 from a nuclear medicine technician, at Rush Copley Medical Center in    |

| Aurora, IL [deleted].  She reported that a patient who was to receive a 4    |

| milliCi unit dose of Tl-201 [Thallium-201] for a heart test instead received |

| a 4 milliCi unit dose of I-131 [Iodine-131] on July 28, 2003.                |

|                                                                              |

| "Circumstances surrounding the event, as reported by the technician,         |

| indicate that both the exterior lead container and syringe were labeled as   |

| being Tl-201.  Although the injection occurred the previous day it was not   |

| determined that I-131 was involved until after the gamma cameras used for    |

| patient imaging were checked a second time on the morning of July 29th.      |

| Service engineers had been called to the site both days to inspect the       |

| cameras after both failed attempts to image the patient.  The cause became   |

| evident when a gamma camera flood source that had been made from what was    |

| thought to be the remaining Tl-201 material in the syringe from 7/29/2003    |

| showed peaks consistent with I-131.  The assayed amount from Monday's        |

| records showed the dose to be within the expected range for a typical 4      |

| milliCi Tl-201 diagnostic doses and as such, was considered to be normal.    |

| The technician indicated that the patient involved had been contacted by the |

| referring physician, the onsite oncologists, the hospital Administrator and  |

| lawyer and was informed as to what had happened.  The hospital has arranged  |

| to perform routine blood analysis throughout the year to monitor any changes |

| in thyroid activity.                                                         |

|                                                                              |

| "The RSO [Radiation Safety Officer] and oncologist at the facility,          |

| [deleted], were then contacted by the Agency.  He indicated that it is very  |

| unlikely that any changes will be noted in the patient.  He reports that the |

| dose administered, is only slightly larger than that typically ordered for   |

| whole body scans using I-131.  Regardless, they have offered to provide      |

| routine blood testing of the patient throughout the year for T3, T4 and T7   |

| thyroid hormones levels as part of a follow up evaluation.                   |

|                                                                              |

| "A call was then made to the Medi Physics/Amersham Health, [deleted] Wood    |

| Dale pharmacy facility where the doses had been prepared the previous        |

| Friday.  [Deleted], Corporate RSO indicated that they were in the process of |

| determining what had occurred but it appeared that when prescriptions and    |

| labels were taken from the computer system a 4 milliCi Tl-201 prescription   |

| was mistakenly put in with 4 other prescriptions for 4 milliCi unit doses of |

| I-131 to be filled. Subsequently, the Tl-201 request was mistakenly filled   |

| as an I-131 prescription. The difference in nuclides was not noted by the    |

| pharmacist when the pre-generated Tl-201 labels were applied to the syringe  |

| and lead container which now held I-131.                                     |

|                                                                              |

| "The Agency sent an investigator to the medical center on the morning or     |

| July 30 to observe the labeling on the container and syringe, receipt        |

| records, gamma camera QA tests and to verify by gamma spectrum analysis the  |

| presence of I-131 as well as to conduct preliminary interviews to obtain     |

| additional facts.  The investigation then moved on to the pharmacy to        |

| continue their review of the event.  Based on those visits, the information  |

| obtained largely confirmed the preliminary notification.  The Agency is      |

| continuing its investigation of the matter and is expecting reports to be    |

| filed by both parties according to regulatory requirements.                  |

|                                                                              |

| "Preliminary estimates of EDE to the whole body of 355 Rem and 11,672 Rad to |

| the thyroid based on ICRP 53 modeling assuming 55% uptake and standard man   |

| conditions has been calculated.  Similar preliminary estimates based on the  |

| package insert assuming 25% uptake resulted in 1,628 Rads and 5,328 Rads     |

| respectively.  The two estimates vary widely because of unknown factors      |

| associated with the patient's condition.  NRC Operations Center was notified |

| of the event at 17[50] on 31 July 2003 and assigned Event Number 40042."     |

|                                                                              |

| *** UPDATED AT 1705 EDT ON 8/1/03 FROM KLINGER TO CROUCH ***                 |

|                                                                              |

| Last paragraph of above report was amended to read as follows:               |

|                                                                              |

| "Preliminary estimates of dose to the thyroid range from 5,300 Rads to       |

| 11,700  Rads.  The two estimates vary widely because of unknown factors      |

| associated with the patient's condition.  NRC Operations Center was notified |

| of the event at 1750 E.S.T  on 31 July 2003 and assigned Event Number        |

| 40042."                                                                      |

+------------------------------------------------------------------------------+



+------------------------------------------------------------------------------+

|Other Nuclear Material                           |Event Number:   40047       |

+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+

| REP ORG:  FROEHLING &ROBERTSON INC             |NOTIFICATION DATE: 08/05/2003|

|LICENSEE:  FROEHLING &ROBERTSON INC             |NOTIFICATION TIME: 09:03[EDT]|

|    CITY:  RICHMOND                 REGION:  2  |EVENT DATE:        08/05/2003|

|  COUNTY:                            STATE:  VA |EVENT TIME:        06:30[EDT]|

|LICENSE#:  45-08890-02           AGREEMENT:  N  |LAST UPDATE DATE:  08/05/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |JAMES MOORMAN        R2      |

|                                                |DOUG BROADDUS        NMSS    |

+------------------------------------------------+                             |

| NRC NOTIFIED BY:  BILL BRIODY                  |                             |

|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |

+------------------------------------------------+                             |

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|BLO1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

+------------------------------------------------------------------------------+



                                   EVENT TEXT                                   

+------------------------------------------------------------------------------+

| STOLEN  MODEL 3411 TROXLER  GAUGE                                            |

|                                                                              |

| A Troxler gauge model # 3411 serial # 10605 containing 4.8 millicuries of    |

| Cs-137 (serial # 408040) and 38.8 millicuries Am-241:Be (serial # 462027)    |

| was stolen from the back of the technician's pickup truck which was parked   |

| in his yard in Norfolk, VA.  The gauge was locked in its molded case and     |

| chained to the truck.  The chain had been cut, and the gauge and case were   |

| removed sometime early this morning or late last night from the truck.   The |

| police were called to the scene and are investigating.  No press release has |

| been issued at this time and no reward has been offered.  The licensee       |

| notified Reg 2.                                                              |

|                                                                              |

| * * * UPDATE AT 1437 EDT ON 08/04/03 FROM BILL BRIODY TO JOLLIFFE * * *      |

|                                                                              |

| At approximately 1200 EDT on  08/04/03,  a private citizen found the gauge   |

| on the side of I-64 in the Norfolk, VA area.  The lock on the case had been  |

| cut and there was no significant damage to the case.  The sources were       |

| undamaged and intact inside the case.  The citizen took the gauge to his     |

| home and notified the VA Department of Transportation who took possession of |

| the gauge.  The licensee plans to submit a written report to NRC Region 2.   |

|                                                                              |

|                                                                              |

| Notified R2DO Steve Cahill and NMSS Doug Broaddus.                           |

+------------------------------------------------------------------------------+