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Event Notification Report for June 26, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/25/2007 - 06/26/2007

** EVENT NUMBERS **


43432 43434 43441 43442 43444

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General Information or Other Event Number: 43432
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CARDINAL HEALTH
Region: 4
City: WEST MONROE State: LA
County:
License #: LA-5119-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/19/2007
Notification Time: 14:37 [ET]
Event Date: 05/16/2007
Event Time: [CDT]
Last Update Date: 06/19/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
GREG MORELL (FSME)

Event Text

LOUISIANA AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO DISPENSING ERROR

The State provided the following information via facsimile:

"Description of Event - A customer called the [Cardinal Health] pharmacy on Wednesday, May 16, 2007 to report that the late injection of Tc-99m sestamibi, a heart imaging agent, showed no heart uptake on the film. Instead there was only soft tissue uptake. The activity dispensed and injected matched the prescription. The next day the patient was brought back to the department and the image indicated that the dose injected was Tc-99m medronate, a bone imaging agent.

"Investigation and Root Causes - A large dose of Tc-99m sestamibi was ordered at 0600 calibrated for 1400. A biliary dose was also ordered at the same time. These were the only two doses drawn at that time. After notification by the hospital, an investigation revealed that the activity and volume remaining in the sestamibi vial plus the volume and activity dispensed matched the total volume and activity of the prepared kit (after correction for decay). The concentration for the sestamibi kit is normally 30% greater than for a bone imaging kit. Since the volume was correct, no flags were detected during dispensing. It is not Cardinal Health policy to test used syringes due to blood borne pathogen hazards. No other clients that were dispensed doses from the same vial reported errors in imaging. From this analysis, Cardinal Health can find no errors on its part to account for the imaging error.

"Actions Taken to Prevent a Recurrence - Cardinal Health has protocols in place to prevent dispensing errors of the type described above. Since the error cannot be attributed to Cardinal Health, corrective action is unnecessary.

LA event Report ID No.: LA070015

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.

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General Information or Other Event Number: 43434
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: OREGON HEALTH SCIENCE UNIVERSITY
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-90013
Agreement: Y
Docket:
NRC Notified By: TERRY LINDSEY
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/20/2007
Notification Time: 18:54 [ET]
Event Date: 06/18/2007
Event Time: 16:00 [PDT]
Last Update Date: 06/20/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
JACK DAVIS (FSME)

Event Text

OREGON AGREEMENT STATE REPORT - POTENTIAL UNDERDOSE TREATMENT TO LIVER

"Written order was requested for a therapy dose of 2.45 GBq (66.2 milliCuries) of Y-90 TheraSphere for treatment to the patient's liver. 1.74 GBq (47 milliCuries) was received from MDS Nordion and used for treatment. Calculation error may have contributed to under treatment with approximately 80 Gray delivered to liver with an intended dose of 110-110 Gray. Concern to not exceed lung dose of 15 Gray achieved with treatment dose at low end of optimal range. Physician notified and will consult with patient to decide whether to conduct additional treatment."


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.

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Other Nuclear Material Event Number: 43441
Rep Org: BLAZOSKY ASSOCIATES, INC
Licensee: BLAZOSKY ASSOCIATES, INC
Region: 1
City: PORT MATILDA State: PA
County: CENTRE
License #: 37-28507-01
Agreement: N
Docket:
NRC Notified By: JAMES DOTTS, RSO
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/25/2007
Notification Time: 10:02 [ET]
Event Date: 06/25/2007
Event Time: 09:40 [EDT]
Last Update Date: 06/25/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
RAY POWELL (R1)
CINDY FLANNERY (FSME)

Event Text

DAMAGED TROXLER MOISTURE DENSITY GAUGE

The Radiation Safety Officer (RSO) of Blazosky Associates, Inc. called to report a damaged Troxler gauge. The damage occurred at the ERPA site on 06/25/07 as a pickup truck backed over the gauge. At the time the gauge was retracted and not actively in-use. The employee at the site called the RSO.

The employee visually examined the gauge and saw that the sources were intact and the shutter still closed. No leakage was found. The RSO will conduct a leak test and radiation check and return the instrument to Troxler.

The gauge is a Troxler Model 3440, Serial Number 29883. Sources were 8 mCi of Cs-137 and 40 mCi of Am-241/Be.

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Other Nuclear Material Event Number: 43442
Rep Org: WYETH RESEARCH LABORATORY
Licensee: WYETH RESEARCH LABORATORY
Region: 1
City: COLLEGEVILLE State: PA
County:
License #: 37-00401-03
Agreement: N
Docket:
NRC Notified By: ROBERT WICKLINE
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/25/2007
Notification Time: 13:09 [ET]
Event Date: 06/11/2007
Event Time: [EDT]
Last Update Date: 06/25/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
RAY POWELL (R1)
CINDY FLANNERY (FSME)
ILTAB (via email) ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

ANALYTICAL INSTRUMENT SHIPPED OFF SITE WITH RADIOACTIVE SOURCES INSTALLED

During a scheduled radioactive source leak test and inventory activity on 18 June 2007, the licensee discovered two Ni-63 sources missing. It was determined that the sources had been shipped off site with the analytical instrument they were installed in on 06/11/07 for an upgrade to a part of the instrument not related to the radioactive sources. The device is a Berger supercritical fluid extraction device and the sealed source device is an Accenture G-2390A, source serial numbers U0891 and U0892. Each source activity level is 14 millicuries. The instrument is scheduled to be returned to the licensee after the upgrade is complete on 06/28/07. The licensee plans to remove the sources from the instrument since their lab has never used that portion of the instrument in the operation of their laboratory.

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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Other Nuclear Material Event Number: 43444
Rep Org: SOIL & MATERIALS ENGINEERING, INC.
Licensee: SOIL & MATERIALS ENGINEERING, INC.
Region: 3
City: PLYMOUTH State: MI
County:
License #: 21-17158-02
Agreement: N
Docket: 30-19574
NRC Notified By: FRANK HENDERSON
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/25/2007
Notification Time: 18:00 [ET]
Event Date: 06/25/2007
Event Time: 15:00 [EDT]
Last Update Date: 06/25/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JAMNES CAMERON (R3)
JACK DAVIS (FSME)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

TROXLER MOISURE DENSITY GAUGE SOURCE FOUND MISSING AFTER FIELD USE

A Troxler Moisture Density Gauge, Model 3430 S/N 22053, was evaluated in the shop after use at a temporary jobsite two hours earlier today in Royal Oak, MI. At the time the Authorized User (AU) attributed the inconsistent G-M readings to survey instrument error. However, further evaluation in the shop noted that the Cs-137 source (8 mCi) connected to the extendable source rod was missing. The licensee is enroute to the temporary jobsite in an effort to locate and recover the missing source.

* * * UPDATE AT 2000 EDT ON 6/25/07 FROM FRANK HENDERSON TO S. SANDIN * * *

The licensee located and recovered the missing source. The source, shielded in a portable container of sand, is enroute to their facility in Plymouth, MI where the licensee will contact Troxler Labs for assistance.

Established conference call between R3 (Shear, Gattone) and the licensee (Henderson).

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

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Thursday, March 29, 2012