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Event Notification Report for September 5, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/04/2007 - 09/05/2007

** EVENT NUMBERS **


43507 43606 43609

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
General Information or Other Event Number: 43507
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: I Q DISTRIBUTORS/DIVERSIFIED MATERIALS SERVICES/DIVERSIFIED
Region: 4
City: HOUSTON State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: JOHN MacKINNON
Notification Date: 07/19/2007
Notification Time: 17:08 [ET]
Event Date: 07/19/2007
Event Time: 14:32 [CDT]
Last Update Date: 09/04/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA SMITH (R4)
E. WILLIAM BRACH (FSME)

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

Event Text

AGREEMENT STATE REPORT FROM THE STATE OF TEXAS

EVENT: Radioactive Material (RAM) found - sealed

License Number: "Unlicensed"

"The agency received a call at 2:15 p.m. today (7/19/07) from DSHS Food & Drug Inspector, (DELETED) inquiring about four radiation devices found with 1994 inspection stickers on each of them. She said there appears to be some concern as of what company owns them and the facility they are located at. She gave me three names of possible companies, or owners:

"I Q Distributors
"Diversified Materials Services
"Diversified Medical Services Inc.

"The facility is located at: 2400 Central Parkway, Suite LP in Houston, Texas 77092. She is currently on location.

"Agency Action Taken: Region 6 RAM Inspector to go to the facility as soon as possible to conduct incident investigation & identify sources."

Texas Incident Number: I-8428

* * * RETRACTION FROM L. HANSON TO P. SNYDER AT 1657 ON 9/4/07 * * *

The NRC received the following information from the Agreement State of Texas via facsimile:

"On 08/23/07, the Agency received a telephone call from the individual who received the gauges from Kellogg Brown & Root, Inc. (KBR) & was given the following information:

"The individual stated that on 03/03/06, he purchased a portion of the building at 2400 Central Parkway, Ste. L, Houston, Texas. The purchaser reported to the Agency that he was not aware that the portion of the building he just bought, Suite L, contained the alloy analyzers found by DSHS inspectors until he was recently contacted by the agency. He stated he thought he bought lab equipment only & was unaware that the building purchase included the alloy analyzers. The other suite, Suite P, is not owned by him & overseen by the initial individual contacted at the site by the agency's inspectors. He is not sure why this individual did not make the suite distinction with the inspectors nor contact him to let him know the building was being inspected.

"He contacted the agency's general licensing acknowledgement (GLA) division & was given the following information: These devices with Fe-55 and Cd-109 sources and no longer issued a GLA so anyone can possess these devices if transferred by manufacturer/distributor. A transfer is allowed if the devices are transferred in their physical location, which occurred when he bought the building.

"Additionally, the agency received documentation from the manufacturer that they removed the RAM sources from the two empty analyzers & shipped the analyzers back to KBR in 1997. The two analyzers which had very low-strength RAM sources were transferred in accordance with the above stated allowance.

"The purchaser asked if the agency could give him information on how he could dispose of the analyzers. The agency responded by forwarding information to the purchaser for possible contacts who could assist him with disposal.

"BASED ON THE ABOVE INFORMATION, THE AGENCY IS REQUESTING A RETRACTION OF THIS INCIDENT, SINCE IT IS NOW DEEMED NON-REPORTABLE."

Notified R4DO (T. Pruett) and FSME (J. Davis).

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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General Information or Other Event Number: 43606
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: PHYSICIAN RELIANCE, LP TEXAS ONCOLOGY
Region: 4
City: FORT WORTH State: TX
County:
License #: L05545-000
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: PETE SNYDER
Notification Date: 08/29/2007
Notification Time: 13:42 [ET]
Event Date: 08/29/2007
Event Time: [CDT]
Last Update Date: 09/04/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
REBECCA NEASE (R4)
CYNTHIA FLANNERY (FSME)

Event Text

AGREEMENT STATE REPORT - HIGHER THAN PRESCRIBED DOSE

"On 08/29/07 at 10:55 a.m., the agency received a call from [the] RSO for the licensee, reporting a High Dose Remote Afterloader (HDR) misadministration that occurred on 08/22/07. The RSO reports that today, 08/29/07, it was discovered that a patient received one HDR treatment on 08/22/07, with 2500 cGy being delivered instead of the planned dose of 500 cGy per fraction for 5 fractions. The RSO reports that the unit was a Varian VariSource loaded with Ir-192. The RSO will include model & serial numbers for the unit & source in his 15-day report to the agency.

"The misadministration was discovered today after an independent physicist's review of the treatment plan.

"The RSO stated the patient denies any symptoms and was being seen by the Radiation Oncologist. He stated the patient's family and referring physician were also notified."

Texas Incident No.: I-8439
Texas Event Report No.: TX-07-43606


* * * UPDATED INFORMATION ON 08/31/07 VIA EMAIL FROM LATISCHA HANSON TO MACKINNON * * *


Telephone call placed to (deleted), Ph.D., L.M.P., RSO for the licensee for updated information from 08/29/07 after the patient was seen by the Radiation Oncologist:

"Deleted reports that the patient was seen by the Radiation Oncologist & is being observed in a 'wait & watch' following. (Deleted) reported that the patient's Pulmonologist has taken over & (deleted) stated the Pulmonologist said 'We may have gotten lucky & even cured the guy.'

"The patient is still reported as doing well, with no adverse side effects being reported, as stated by (deleted).

"(Deleted) stated a CT was performed prior to the planned second treatment on 08/29/07, with no adverse effects viewed on the CT scan.

" ***ADDITIONAL NOTE TO ORIGINAL REPORTED INFORMATION***

"Deleted reported on 08/29/07 that this HDR misadministration occurred as a result of the incorrect isodose line being chosen & entered into the treatment planning system. (Deleted) reported that the treatment planning system then normalized the calculations to this incorrect isodose line & the resulting treatment dose was what was delivered on the first treatment day. (Deleted) stated the Oncologist signed & approved this treatment plan & that (deleted) himself, did a second calculation check on the treatment plan. The calculation error was caught by an independent physicist PRIOR to the planned second treatment.

"Incident Investigations will continue to update this incident as current information is received.

"Incident Investigation personnel plan to conduct an onsite investigation upon receipt and review of the required 15-day report from the licensee."

FSME EO (Sandra Wastler) & R4DO (R. Nease) notified.


* * *UPDATE ON 09/04/07 FROM LATISCHA HANSON VIA EMAIL TO MACKINNON * * *

"On 08/29/07 at 10:55 a.m., the agency received a call from (delete), L.M.P., RSO for the licensee, reporting a High Dose Remote Afterloader (HDR) misadministration that occurred on 08/22/07. The RSO reports that today, 08/29/07, it was discovered that a patient received one HDR treatment on 08/22/07, with 2500 cGy being delivered instead of the planned dose of 500 cGy per fraction for 5 fractions. The RSO reports that the unit was a Varian VariSource loaded with Ir-192. The RSO will include model & serial numbers for the unit & source in his 15-day report to the agency.

"The misadministration was discovered today after an independent physicist's review of the treatment plan.

"The RSO stated the patient denies any symptoms & was being seen by the Radiation Oncologist. He stated the patient's family & referring physician were also notified."

R4DO (Pruett) & FSME (Jack Davis) notified.



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: 43609
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: ENVIRONMENTAL ANALYSTS
Region: 4
City: NEW ORLEANS State: LA
County:
License #: GL-266
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/30/2007
Notification Time: 11:22 [ET]
Event Date: 08/13/2007
Event Time: [CDT]
Last Update Date: 08/30/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
REBECCA NEASE (R4)
ILTAB EMAIL ()
CINDY FLANNERY (FSME)

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

Event Text

AGREEMENT STATE REPORT - LOST GAS CHROMATOGRAPH

The licensee provided the following information via facsimile:

"A portable gas chromatograph with a 15 mCi source of Ni-63 was lost during Hurricane Katrina when the levees broke. This is a General License device. LDEQ was not notified of this loss until August 13, 2007."

LA Event Report - LA070025

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.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012