United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2005 > June 14

Event Notification Report for June 14, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/13/2005 - 06/14/2005

** EVENT NUMBERS **


41756 41757 41763 41767

To top of page
General Information or Other Event Number: 41756
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UNIVERSITY OF FLORIDA SHANDS HOSPITAL
Region: 1
City: GAINSVILLE State: FL
County:
License #: 0031-1
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS
HQ OPS Officer: BILL GOTT
Notification Date: 06/08/2005
Notification Time: 08:08 [ET]
Event Date: 05/25/2005
Event Time: [EDT]
Last Update Date: 06/08/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1)
TOM ESSIG (NMSS)

Event Text

AGREEMENT STATE REPORT

The State provided the following information via email:

"The patient was to receive 2 GigaBecquerel (GBq) (Yttrium-90) from siraspheres. Backpressure from the liver catheter popped the tubing off the 3-way stopcock; approximately 25% of the material was spilled before the tubing could be re-attached. A lower flow rate was used and no further problems were encountered. The spill was contained in the case around the stopcock. Patient received approximately 75% of the material/intended dose. The licensee will send a letter explaining the event. Determination of whether this qualifies as a medical event is the reason for the late NRC notification. Florida continues to investigate.

Florida event number: FL05-086

To top of page
General Information or Other Event Number: 41757
Rep Org: COLORADO DEPT OF HEALTH
Licensee: MARTEK BIOSCIENCES
Region: 4
City: BOULDER State: CO
County:
License #: 1080-01
Agreement: Y
Docket:
NRC Notified By: THOMAS PENTACOST
HQ OPS Officer: MIKE RIPLEY
Notification Date: 06/08/2005
Notification Time: 12:00 [ET]
Event Date: 06/03/2005
Event Time: [MDT]
Last Update Date: 06/08/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
RICHARD CORREIA (NMSS)

Event Text

COLORADO AGREEMENT STATE REPORT - INSTRUMENT SOURCE FAILURE AND SOURCE MATERIAL PLACED IN UNCONTROLLED STORAGE LOCATION

The State provided the following information via facsimile:

"On Monday, June 6, 2005, the Department received a call from the RSO for Martek Biosciences Boulder. He was reporting an incident that occurred at his facility on Friday, June 3, 2005.

"Martek Biosciences is a small research laboratory authorized to used milliCurie quantities of P-32, C-14, and H-3. Martek has a Beckman model 3801 liquid scintillation counter. The counter contains an internal 30 microCurie Cs-137 calibration source.

"The licensee's RSO reported that the liquid scintillation counter had been producing unusual results and a request for service was made to Beckman. A Beckman serviceman arrived at the facility on Friday to replace the 30 microCurie Cs-137 source. He came without survey equipment and did not have a lab coat. On disassembly of the device for source removal and replacement, it was determined that the source had disintegrated. The licensee RSO surveyed his facility and found contamination on the floor and the lab coat he had loaned to the Beckman serviceman. He decontaminated the areas where he found contamination.

"The Department contacted the Beckman serviceman by phone to discuss the incident. He indicated that the remains of the source and some of the contaminated lead shielding had been packaged and removed from the facility. This package was being stored in a rented storage facility pending return to Beckman. The Beckman serviceman did not know the exact address of the storage facility. At the time of the phone conversation, the Beckman serviceman was on vacation and was heading out of state. He was confident that there was no concern for contamination of the package or himself due to the surveys conducted by the licensee RSO.

"The Department contacted Beckman to obtain additional information on the 3801 liquid scintillation counter. He indicated that this device is generally licensed and is equivalent to the model 5801. The Beckman representative provided a copy of his California license and a copy of the request to amend the device registry sheet for the liquid scintillation counter. Apparently, Beckman is aware of other source failures for the liquid scintillation counter and has asked for a limited operational life of the source. The Beckman representative was not able to provide the actual address for the storage facility and he could not provide the names of any other service representatives in Colorado who might have access to the storage shed. He indicated that he would provide that information the next day.

"Tuesday, June 7, 2005: In phone messages from the Beckman representative the Department received the address of the storage facility and name of the regional service manager for Beckman.

"Wednesday, June 8, 2005: The Department received a call from the Beckman service manager. He indicated that there are two service representatives who have the key to the storage shed. The two Colorado service representatives are the only persons with the keys to the storage shed. One of the Beckman service representatives is out of state and a second is currently in Albuquerque, NM.

"The Beckman service manager indicated that the Beckman serviceman should not have removed the source from the Martek facility. He also indicated that the shed did not contain any other sources and that it was only used for the storage of parts. One of the Beckman service representative is expected to return to Denver on Thursday morning. He will open the shed for inspection by the Department.

"Additional data to be provided to complete this report pending the inspection at Martek and the storage facility."

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 41763
Rep Org: EDWARD W. SPARROW REGIONAL CENTER
Licensee: EDWARD W. SPARROW REGIONAL CENTER
Region: 3
City: LANSING State: MI
County:
License #: 21-01430-01
Agreement: N
Docket:
NRC Notified By: TRACY MAUDRIE
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/10/2005
Notification Time: 14:07 [ET]
Event Date: 06/10/2005
Event Time: [EDT]
Last Update Date: 06/13/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JULIO LARA (R3)
TOM ESSIG (NMSS)

Event Text

FRACTIONAL DOSE DELIVERED DIFFERED FROM THE PRESCRIBED DOSE

"A hyperthyroid therapy patient received one of the intended two Nal-131 capsules sent by the radio pharmacy for the therapy. The patient received 10.2 mCi in one capsule instead of the intended 20.6 mCi in two capsules. Both capsules were received in one plastic vial inside of a lead shield. The entire vial was assayed and the assay of 20.6 mCi was within 10% of the prescribed dose of 20.0 mCi. The technologist failed to notice that there were two capsules in the vial because a desiccant inside the vial blocked the view of the second capsule and prevented the second capsule from leaving the vial. Normally, hyperthyroid therapy doses are received in one capsule. Therefore, the technologist was not expecting a second capsule.

"The radio pharmacy discovered the second capsule when the package was returned to the pharmacy the next day, June 10, 2005. They called the Nuclear Medicine department at 8:30 am on June 10, 2005. The prescribing physician was called and he requested that the patient receive the second capsule. The patient returned to the Nuclear Medicine department at 10:00 am on June 10, 2005 and received the second capsule, which assayed at 9.74 mCi at that time. The total dose the patient received was 19.94 mCi.

"Why the event occurred: Hyperthyroid therapy doses are normally received in one capsule. The technologist was not expecting a second capsule. The desiccant placed in the vial by the radio pharmacy obscured the second capsule from the technologist's sight. The desiccant also prevented the second capsule from coming out of the vial when the first capsule came out of the vial.

"Effect on the patient: The prescribing physician does not believe this event will have a negative effect on the patient as she received the remainder of the dose within 24 hours.

"To prevent recurrence of this action the licensee will assay all applicable capsule vials after the patient has received their dose, but before the patient leaves the department. This will ensure that no capsules remain in the vial.

"Certification that the licensee notified the individual: The patient was notified by telephone on June 10, 2005 and the patient returned to the hospital to receive the second capsule of 9.74 mCi Nal-131."

* * * RETRACTION ON 06/13/05 AT 1720 BY MARTY JOHNSON TO CHAUNCEY GOULD * * *

Based on a re-reading of Part 35 and a conversation with Region 3 Materials Inspection and Materials Licensing Branches it was determined that this is not a medical event and should be retracted.

Notified Reg 3 RDO (Patrick Louden) and NMSS (Patricia Holahan)

To top of page
Other Nuclear Material Event Number: 41767
Rep Org: U.S. ARMY
Licensee: U.S. ARMY
Region: 3
City: ROCK ISLAND State: IL
County:
License #: 12-000712-06
Agreement: Y
Docket:
NRC Notified By: JEFF HACENNER
HQ OPS Officer: BILL GOTT
Notification Date: 06/13/2005
Notification Time: 09:39 [ET]
Event Date: 06/10/2005
Event Time: [CDT]
Last Update Date: 06/13/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
TODD JACKSON (R1)
PATRICK LOUDEN (R3)
TOM ESSIG (NMSS)
TAS (email) ()

Event Text

STOLEN M-22 AUTOMATIC CHEMICAL DETECTORS

Five M-22 Automatic Chemical Detectors were stolen from the NBC Room (locked secure storage) at Fort Campbell, KY. The theft was discovered on June 10, 2005. Each device contains 20 milliCuries of Nickel - 63. The Army Criminal Investigative Service and the Fort Campbell Military police are conducting an investigation. The Device serial number/source serial numbers are: Y14M0989/Y14C0989, Y14M08283/Y14D08283, Y14M08429/Y14D08429, Y14M08075/Y14D08075, Y14M08548/Y14D08548.

The licensee notified R3 (D. Wiedeman)

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012