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Event Notification Report for February 28, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/27/2008 - 02/28/2008

** EVENT NUMBERS **


43999 44003 44008 44010

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Hospital Event Number: 43999
Rep Org: VIRGINIA COMMONWEALTH UNIVERSITY
Licensee: VCU MEDICAL CENTER
Region: 1
City: RICHMOND State: VA
County:
License #: 45-00048-17
Agreement: N
Docket:
NRC Notified By: DEAN BROGA
HQ OPS Officer: JOE O'HARA
Notification Date: 02/21/2008
Notification Time: 13:22 [ET]
Event Date: 02/20/2008
Event Time: 12:40 [EST]
Last Update Date: 02/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RAY POWELL (R1)
GREG MORELL (FSME)

Event Text

POTENTIAL MEDICAL EVENT - UNDERDOSE OF Y-90 MICROSPHERES

The licensee reported that a patient being treated for liver cancer received approximately half of the prescribed dose of Y-90 microspheres. The licensee calculates the patient received 16 Grays instead of the prescribed 38 Grays.

The treatment is performed in three flushes. The patient receives 50% of the medication in the first flush and the remaining 50% in the second flush. The third flush is performed to ensure all the prescribed medication has been applied to the patient. In this case, the patient received the first flush but the second flush wouldn't go through the line. The licensee is investigating a problem with the three-way valve used in the treatment or potentially a crimp in the line which caused a blockage.

Both the patient and prescribing physician are aware of this problem, and the other half of the patient's therapy is planned for a future time period.


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: 44003
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: BOEING
Region: 4
City: SEATTLE State: WA
County:
License #: WN-I005-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: JOE O'HARA
Notification Date: 02/22/2008
Notification Time: 15:32 [ET]
Event Date: 02/07/2008
Event Time: [PST]
Last Update Date: 02/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4)
GREG SUBER (FSME)
CANADA ()

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

Event Text

AGREEMENT STATE REPORT - LOST ELECTRON CAPTURE CELL CONTAINING NICKEL - 63 SOURCE

"This is notification of an event in Washington State as reported to or investigated by the WA Department of Health, Office of Radiation Protection.

"The Boeing Company reported February 7th they are unable to find one gas chromatograph electron capture cell that contains 555 MBq (15 millicuries) of nickel-63. The Licensee became aware of the missing source on January 7, 2008, during a routine survey and inventory of their radioactive waste area. Based on their investigation, the licensee thinks the source was disposed of as radioactive waste in a shipment sent to the Low Level Radioactive Waste site in December 2007. The licensee attributes this to staff not following the established procedures for the transfer and disposal of the source. The person assigned waste area duties in December has subsequently left employment with Boeing. Confirming this directly is unlikely to happen. The Boeing RSO has reviewed the procedures and believes that when they are followed they are adequate to prevent loss of a source. However, the RSO will now require two people to be involved in the radioactive waste packaging process with both signing shipment documents before they are complete. The Boeing RSO reviewed the new procedure with the radiation safety staff. We are told, the discussion emphasized the importance of following the procedures. The RSO will have the waste manifest changed to show addition of the source.

"Event Report #WA-08-011."

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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General Information or Other Event Number: 44008
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: OHMART/VEGA CORPORATION
Region: 3
City: CINCINNATI State: OH
County:
License #: 03214310020
Agreement: Y
Docket:
NRC Notified By: JAMES STEPHEN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/25/2008
Notification Time: 10:00 [ET]
Event Date: 02/22/2008
Event Time: [EST]
Last Update Date: 02/27/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE PASSEHL (R3)
MICHELE BURGESS (FSME)

Event Text

OHIO AGREEMENT STATE REPORT - TWO CONTAMINATED INDIVIDUALS

The following information was obtained from the Ohio Department of Health via email:

"Initial Notification: The Bureau [Ohio Department of Health Bureau of Radiation Health] was notified via e-mail at approximately 4:00 PM on Friday, 2/22/08 that the licensee experienced a contamination incident in their source handling facilities. The e-mail was sent to a Bureau staff member who was out of the office until Monday, 2/25/08. The e-mail was retrieved by the Bureau staff member at approximately 6:00 AM on Monday, 2/25/08.

"The contamination incident involved two (2) employees who were working in the source disposal room. One employee was attempting to retrieve a source from one of the licensee's own SR-1 source holders (vintage 1972) using the saw. In doing so, he breached the 300 mCi Cs-137 source and contaminated the area with microspheres. The licensee's emergency procedures were immediately activated. Employees verified that there was no floor contamination outside of the disposal room through use of a pancake probe and then maslin wipes. The ventilation system was turned off. No activity was found outside the doors to the disposal room. A third employee went into the disposal room to do surveys and wipes and confirmed that contamination is present in the room.

"The first employee involved in the contamination incident was removed from the disposal room, dressed in two Tyvek suits, and moved from the disposal room to the enclosed area outside that room where he could be frisked. He exhibited contamination on one hand and on one leg. The second employee, having taken additional wipes and surveys to determine the locations of contamination, was then removed. Contamination was detected on his hands as well as his shirt and pants. Decontamination commenced on both individuals. This information was contained in the initial e-mail notification from the licensee and was current as of 2/22/08.

"Follow-up: The Bureau initiated a phone call with licensee management at approximately 8:15 AM on Monday, 2/25/08. During this call the licensee stated that the facility contamination is limited to the source handling room, which has been isolated and sealed with tape. The licensee further stated that no further decontamination work was done over the weekend once the individuals involved were decontaminated and the source handling room was secured. The licensee stated that the determination was made that the contamination on the two individuals involved was limited primarily to the clothing worn. This clothing was removed, and any areas of their body showing contamination were successfully decontaminated. One of the individuals had shown contamination near his nose. Surveys of tissues used by him to blow his nose during decontamination indicated no contamination, but nasal swabs of this individual were not done by the licensee. The licensee stated that bioassays of the contaminated individuals were not planned at this time. The Bureau informed the licensee that bioassays would be necessary for these individuals.

"The Bureau has dispatched two inspectors to the licensee's facility in Cincinnati, Ohio, to arrive there late morning Monday, 2/25/08. The licensee has been instructed not to take any further actions regarding clean-up of the contaminated areas until the Bureau inspectors arrive. The Bureau will require a written action plan from the licensee for the decontamination process, which the licensee stated will be performed by an outside contractor."

* * * UPDATE PROVIDED BY STATE OF OHIO VIA EMAIL (STEPHEN JAMES) TO JEFF ROTTON AT 1207 EST ON 02/27/08 * * *

The following information was provided by the state via email:

"UPDATE TO INITIAL REPORT: Two inspectors from the Bureau visited the licensee's facilities on Monday, 2/25/08. The inspectors verified that the licensee had secured ventilation and sealed off the sealed source disposal room where the incident occurred to prevent the spread of contamination. The licensee sealed off the room using duct tape around the doors and along the floor of the doorways. The inspectors also interviewed the individuals involved in the operations that resulted in the breaching of the source to determine the steps taken once the individuals became aware that the source had been cut into. The Bureau inspectors conducted confirmatory surveys, including wipe tests, of the area around the contaminated room and of the ventilation system discharges. These surveys indicated no evidence of contamination outside of the source disposal room. The Bureau also issued an order to the licensee on Monday, 2/25/08, prohibiting any additional sealed source removal operations by the licensee until further notice.

"The Bureau contacted the licensee via telephone on Tuesday, 2/26/08, to discuss ongoing dose reconstruction efforts and the licensee's plans for decontamination of the sealed source disposal room. The licensee stated that the two individuals involved were scheduled for whole-body counting at the University of Cincinnati later in the week, which was the first available time this could be done. The licensee is also working on dose estimates from the incident, which will be provided to the Bureau as soon as they are completed. The licensee is in the process of selecting a contractor to perform the clean-up activities and will inform the Bureau once a contractor has been selected and a start date established. The licensee was informed that the Bureau will send representatives to attend the initial meeting with the licensee and the clean-up contractor to discuss the plan of action and timeline. The licensee was also informed that the Bureau would send inspectors to the facility periodically during the clean-up to perform confirmatory measurements and review the progress to date. The licensee was reminded that they were subject to the NRC M&D security orders and may need to address those as it related to the escorting of contractor personnel."

Ohio Incident Reference number: OH2008-011

Notified R3DO (Kozak) and FSME EO (Michele Burgess).

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Other Nuclear Material Event Number: 44010
Rep Org: ADVANCED CARE MEDICAL
Licensee: ADVANCED CARE MEDICAL
Region: 1
City: OXFORD State: CT
County:
License #: 06-30764-01
Agreement: N
Docket:
NRC Notified By: WAYNE RICHARDSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/27/2008
Notification Time: 15:50 [ET]
Event Date: 02/27/2008
Event Time: 10:45 [EST]
Last Update Date: 02/27/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
LAWRENCE DOERFLEIN (R1)
MICHELE BURGESS (FSME)

Event Text

UNPLANNED CONTAMINATION CAUSED BY DAMAGED I-125 SEED

During assembly of a brachytherapy seed strand in the production lab, one seed was damaged and contaminated the working tool. The seed was I-125 containing 0.399 millicuries. Contamination levels of the working tool was determined to be 17,224 dpm. Decontamination of the working tool was completed and restored working tool to normal background levels. The other 82 seeds that were in the vicinity of the working tool have been quarantined.

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