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Event Notification Report for August 27, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/26/2004 - 08/27/2004

** EVENT NUMBERS **


40976 40979

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General Information or Other Event Number: 40976
Rep Org: NV DIV OF RAD HEALTH
Licensee: GEOTEK, INC.
Region: 4
City: LAS VEGAS State: NV
County:
License #: 00-11-0348-01
Agreement: Y
Docket:
NRC Notified By: STAN MARSHALL
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/23/2004
Notification Time: 12:55 [ET]
Event Date: 08/19/2004
Event Time: 16:30 [PDT]
Last Update Date: 08/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JOHNSON (R4)
JOHN HICKEY (NMSS)

Event Text

NEVADA: AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE


"1. Event Report ID No. NV-04-005

"2. License name, address, license No: Geotek, Inc.; 8835 S. Escondido Street, Suite A; Las Vegas, Nevada 89119-3 828, 00-11-0348-01

"3. Nature of Event, Date and time of occurrence: Theft of a portable moisture/density gauge on 8/19/04, about 4:30 pm.

"4. Date notified of event by licensee or non-licensee: August 20, 2004

"5. Radionuclide, activity: Cesium 137-10 millicuries and Americium 241-50 milliCuries

"6. Any exposures (indicate short and long-term effects): Unknown

"7. Sealed source, device, etc. (make, model #, serial #): CPN-131 sealed source, CPN Model MC-3 gauge, serial number M34125837

"8. Leak test information, if applicable: Unknown

"9. Equipment (make, model #, serial #), and clear description of any equipment problems: See # 7 above

"10. Persons involved, consequences: (Deleted), no consequences known

"11. Transportation, identify shipper, package type and ID No.: N/A

"12. Abnormal Occurrence (Y/N): N

"13. Cause and contributing factors: The chain, securing the gauge case in the truck, was cut with bolt cutters and the gauge in its case was stolen

"14. Notifications: patient, physician: N/A

"15.Licensee corrective actions: Will perform investigation to determine root cause

"16.Provide status through resolution (update record when found)

"17. Notifications, local police, FBI and other States; as needed: Clark County Metropolitan Police

"18. Enforcement Actions: Under investigation

"19. Identify any possible generic safety concerns: N/A

"20. Potential for others to experience the save event: Unknown

"This incident was reported to Ms. Linda McLean, NRC Region IV, on 8/20/04 by telefax."

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General Information or Other Event Number: 40979
Rep Org: ALABAMA RADIATION CONTROL
Licensee: NORTHEAST ALABAMA REGIONAL MEDICAL CENTER
Region: 1
City: Montgomery State: AL
County:
License #: 315
Agreement: Y
Docket:
NRC Notified By: DAVID TUBERVILLE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/24/2004
Notification Time: 08:52 [ET]
Event Date: 08/10/2004
Event Time: [CDT]
Last Update Date: 08/24/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
EUGENE COBEY (R1)
GARY JANOSKO (NMSS)

Event Text

MEDICAL MISADMINISTRATION

The following information was received from the State of Alabama Department of Public Health via facsimile:

"SUBJECT: Licensee identification of I-131 Misadministration.

"By telefax notification on August 17, 2004, Northeast Alabama Regional Medical Center (Alabama Radioactive Material License No. 315) notified the State of Alabama of a misadministration involving Iodine-131.

"In the telefaxed report, the licensee indicated that the event occurred on August 10, 2004 and was discovered on August 12, 2004. The dose prescribed was 25 microcuries of I-131 and the dose administered was 3.0 millicuries. Based on the information supplied by the licensee, it appears that the imaging technologist misunderstood the referring physician's request and the dose was not approved by the authorized user. The licensee indicated in their report that there was no apparent effects to the patient. Corrective measures included reinstructing personnel and ensuring that all procedures are approved by the authorized user.

"At this time, the Office of Radiation Control is requesting additional information from the licensee. Once made available, the information will be supplied via the NMED database system."

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Friday, March 30, 2012