Event Notification Report for December 22, 2008
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/21/2008 - 12/22/2008
General Information or Other
Event Number: 45005
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: HAHNEMANN UNIVERSITY HOSPITAL
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0927
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: KARL DIEDERICH
Licensee: HAHNEMANN UNIVERSITY HOSPITAL
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0927
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: KARL DIEDERICH
Notification Date: 04/21/2009
Notification Time: 10:26 [ET]
Event Date: 12/22/2008
Event Time: 00:00 [EDT]
Last Update Date: 04/21/2009
Notification Time: 10:26 [ET]
Event Date: 12/22/2008
Event Time: 00:00 [EDT]
Last Update Date: 04/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
PAUL KROHN (R1)
ANGELA MCINTOSH (FSME)
PAUL KROHN (R1)
ANGELA MCINTOSH (FSME)
MIS-ADMINISTRATION OF I-125 SUBCUTANEOUSLY VICE INTRAVENOUSLY
The following abnormal occurrence information was received via e-mail:
"PA NMED PA090013.
"Date and Place: 12-22-2008; Hahnemann University Hospital, Philadelphia, PA.
"Procedure/Dose (Actual vs. Intended), Nature, and Probable Consequences: Patient prescribed 50 mCi of Iodine-125 monoclonal antibody to be administered intravenously. On December 22, 2008 the injection was made subcutaneously when patient's port was not located properly during the injection. Estimated skin dose is 360-710 rads.
"Notification: Patient was notified at the time of the event that the injection was subcutaneous rather than intravenous.
"Health Effect: Doctor is confident that the therapeutic effects of this dosage have still been received by the patient. There have been no noted skin effects reported to date.
"Cause or Causes: The nurse did not have the port completely visualized and admitted to not palpating the site as well as possible
"Actions Taken to Prevent Recurrence: Staff was retrained in December 2008 that patients with ports are to disrobe completely and be palpated to ensure that the injection is occurring within the port.
"State Agency: Just received notification of medical event, follow-up inspection to be performed by the State.
"This event is closed for the purpose of this report."
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.
The following abnormal occurrence information was received via e-mail:
"PA NMED PA090013.
"Date and Place: 12-22-2008; Hahnemann University Hospital, Philadelphia, PA.
"Procedure/Dose (Actual vs. Intended), Nature, and Probable Consequences: Patient prescribed 50 mCi of Iodine-125 monoclonal antibody to be administered intravenously. On December 22, 2008 the injection was made subcutaneously when patient's port was not located properly during the injection. Estimated skin dose is 360-710 rads.
"Notification: Patient was notified at the time of the event that the injection was subcutaneous rather than intravenous.
"Health Effect: Doctor is confident that the therapeutic effects of this dosage have still been received by the patient. There have been no noted skin effects reported to date.
"Cause or Causes: The nurse did not have the port completely visualized and admitted to not palpating the site as well as possible
"Actions Taken to Prevent Recurrence: Staff was retrained in December 2008 that patients with ports are to disrobe completely and be palpated to ensure that the injection is occurring within the port.
"State Agency: Just received notification of medical event, follow-up inspection to be performed by the State.
"This event is closed for the purpose of this report."
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.
General Information or Other
Event Number: 44741
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: CHEVRON USA, INC.
Region: 4
City: SALT LAKE CITY State: UT
County:
License #: UT-1800057
Agreement: Y
Docket:
NRC Notified By: DAVID HOGGE
HQ OPS Officer: RYAN ALEXANDER
Licensee: CHEVRON USA, INC.
Region: 4
City: SALT LAKE CITY State: UT
County:
License #: UT-1800057
Agreement: Y
Docket:
NRC Notified By: DAVID HOGGE
HQ OPS Officer: RYAN ALEXANDER
Notification Date: 12/23/2008
Notification Time: 14:30 [ET]
Event Date: 12/22/2008
Event Time: 15:00 [MST]
Last Update Date: 01/21/2009
Notification Time: 14:30 [ET]
Event Date: 12/22/2008
Event Time: 15:00 [MST]
Last Update Date: 01/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GREG WERNER (R4)
ROBERT LEWIS (FSME)
GREG WERNER (R4)
ROBERT LEWIS (FSME)
UTAH AGREEMENT STATE REPORT
The State of Utah reported that one of their licensees, Chevron USA, Inc., reported a source disconnect on a custom made Ronan level density gauge at their refinery. The gauge was located in a dry storage tank with two pressure vessels inside. The source was inside the storage tank and was retrieved by a health physics contractor. The source is currently stored at the licensee's facility in a locked storage shed, surrounded by lead bricks. The licensee is awaiting the arrival of the Ronan representative on-site. There were no excessive exposures to either workers or the public.
The source was 100 mCi of Cs-137 and is a Model SA-4.
* * * UPDATE AT 1416 ON 1/21/09 FROM DAVID HOGGE TO MARK ABRAMOVITZ * * *
The following information was submitted by the state by fax:
"Approximately 3:00 PM on December 22, 2008, Chris Crossman RSO from Chevron called to report that a Ronan Model SA-4 source holder containing a Cesium-137 source with approximately 100 mCi (s/n: 2231 CM) became unattached from a belt that the source holder was clamped to and fell to the ground and landed inside the storage silo it was mounted to.
"Upon discovery, the RSO was notified and the area was immediately cordoned off, and perimeter access was maintained. A service licensee was called to the facility to perform surveys of the area and retrieve the source. The source was sequestered and placed into a lead brick cave in a secured storage shed on the licensee's premises. Ronan Engineering, who built this custom device for Chevron, has been contacted and they indicated that they will be out sometime after the first of the year to re-install the source.
"On January 13, 2009, a reciprocity inspection and investigation by the Utah DRC was performed at the Chevron Refinery with a Ronan representative, [DELETED], and [DELETED] the Chevron instrument technician who initially reported the incident.
"The source holder is comprised of an 18 inch stainless steel rod with a clamp at one end. This clamp, the 'tape grabber,' clamps to the end of a guide belt. Over the clamp is a stainless steel threaded sleeve, held in place with a small tension screw. At the opposite end of the source rod is the Cs-137 source mounted inside the stainless steel rod. Over the source is a cylindrical collimator which can open to fine tune the exposure field. The source rod is mounted inside a dry 'guide tube' that is raised and lowered inside the tank, via an electronic pulley mechanism. The pulley also controls in tandem, at the same level as the source, a detector mounted on the outside of the tank, also in a dry guide tube.
"By using a dummy source holder for comparison, the source holder and clamp were briefly examined while inside the lead cave. The source holder was found intact and a previously done leak test indicated no leakage from the source. Closer scrutiny of the clamp end (the Tape Grabber) revealed that the set screw that holds the tape grabber together had partially loosened. Furthermore, small tension screw that holds the outer sleeve in place had worked itself loose and somehow sheared off. With the inner screw loose and the outer screw the weight of the source holder is all that was needed to pull the guide belt out of the clamp.
"Root Cause: Failure of equipment to perform as designed. Poor design and testing of design contributed to the failure of this device.
"Corrective Actions: The licensee called Rocky Mountain Health Physics [RMHP] who came out and relocated the source and source holder to a secure storage shed on the licensee's premises. The area where the source had fallen was roped off and all personnel in the immediate area were escorted away. RMHP wipe tested the source holder and there was no evidence of a leaking source. The licensee then called Ronan Engineering to report the failure of the device and Ronan indicated they would send a representative to the refinery in January 2009."
Utah Incident Number: UT 08-0006
Notified the R4DO (Farnholtz) and FSME (Chang).
The State of Utah reported that one of their licensees, Chevron USA, Inc., reported a source disconnect on a custom made Ronan level density gauge at their refinery. The gauge was located in a dry storage tank with two pressure vessels inside. The source was inside the storage tank and was retrieved by a health physics contractor. The source is currently stored at the licensee's facility in a locked storage shed, surrounded by lead bricks. The licensee is awaiting the arrival of the Ronan representative on-site. There were no excessive exposures to either workers or the public.
The source was 100 mCi of Cs-137 and is a Model SA-4.
* * * UPDATE AT 1416 ON 1/21/09 FROM DAVID HOGGE TO MARK ABRAMOVITZ * * *
The following information was submitted by the state by fax:
"Approximately 3:00 PM on December 22, 2008, Chris Crossman RSO from Chevron called to report that a Ronan Model SA-4 source holder containing a Cesium-137 source with approximately 100 mCi (s/n: 2231 CM) became unattached from a belt that the source holder was clamped to and fell to the ground and landed inside the storage silo it was mounted to.
"Upon discovery, the RSO was notified and the area was immediately cordoned off, and perimeter access was maintained. A service licensee was called to the facility to perform surveys of the area and retrieve the source. The source was sequestered and placed into a lead brick cave in a secured storage shed on the licensee's premises. Ronan Engineering, who built this custom device for Chevron, has been contacted and they indicated that they will be out sometime after the first of the year to re-install the source.
"On January 13, 2009, a reciprocity inspection and investigation by the Utah DRC was performed at the Chevron Refinery with a Ronan representative, [DELETED], and [DELETED] the Chevron instrument technician who initially reported the incident.
"The source holder is comprised of an 18 inch stainless steel rod with a clamp at one end. This clamp, the 'tape grabber,' clamps to the end of a guide belt. Over the clamp is a stainless steel threaded sleeve, held in place with a small tension screw. At the opposite end of the source rod is the Cs-137 source mounted inside the stainless steel rod. Over the source is a cylindrical collimator which can open to fine tune the exposure field. The source rod is mounted inside a dry 'guide tube' that is raised and lowered inside the tank, via an electronic pulley mechanism. The pulley also controls in tandem, at the same level as the source, a detector mounted on the outside of the tank, also in a dry guide tube.
"By using a dummy source holder for comparison, the source holder and clamp were briefly examined while inside the lead cave. The source holder was found intact and a previously done leak test indicated no leakage from the source. Closer scrutiny of the clamp end (the Tape Grabber) revealed that the set screw that holds the tape grabber together had partially loosened. Furthermore, small tension screw that holds the outer sleeve in place had worked itself loose and somehow sheared off. With the inner screw loose and the outer screw the weight of the source holder is all that was needed to pull the guide belt out of the clamp.
"Root Cause: Failure of equipment to perform as designed. Poor design and testing of design contributed to the failure of this device.
"Corrective Actions: The licensee called Rocky Mountain Health Physics [RMHP] who came out and relocated the source and source holder to a secure storage shed on the licensee's premises. The area where the source had fallen was roped off and all personnel in the immediate area were escorted away. RMHP wipe tested the source holder and there was no evidence of a leaking source. The licensee then called Ronan Engineering to report the failure of the device and Ronan indicated they would send a representative to the refinery in January 2009."
Utah Incident Number: UT 08-0006
Notified the R4DO (Farnholtz) and FSME (Chang).