Event Notification Report for July 09, 2009
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/08/2009 - 07/09/2009
General Information or Other
Event Number: 45291
Rep Org: LOUISIANA DEQ
Licensee: GE HEALTHCARE
Region: 4
City: NEW ORLEANS State: LA
County:
License #: LA-5470-L01
Agreement: Y
Docket:
NRC Notified By: ANN TROXLER
HQ OPS Officer: DONG HWA PARK
Licensee: GE HEALTHCARE
Region: 4
City: NEW ORLEANS State: LA
County:
License #: LA-5470-L01
Agreement: Y
Docket:
NRC Notified By: ANN TROXLER
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/25/2009
Notification Time: 10:57 [ET]
Event Date: 07/09/2009
Event Time: 00:00 [CDT]
Last Update Date: 08/25/2009
Notification Time: 10:57 [ET]
Event Date: 07/09/2009
Event Time: 00:00 [CDT]
Last Update Date: 08/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GEOFFREY MILLER (R4DO)
ANGELA MCINTOSH (FSME)
GEOFFREY MILLER (R4DO)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING RADIOPHARMACEUTICALS
The following report was received from the State of Louisiana via facsimile:
"On July 9, 2009, a facility reported a mislabeled unit dose from GE Healthcare nuclear pharmacy. Three 20 mCi unit doses of Tc-99m MDP (bone scans) were ordered by Ochsner [a medical facility]. Two patients were injected. After viewing the images, it was determined that the unit doses were mislabeled. An investigation of GE Healthcare was performed. A preliminary cause was determined to be a mix up of MDP cold vial with DTPA [renal scans] as they closely resemble each other with the same vial configuration and same color label. Contributing factors leading to the incident were Tc-99m/Mo-99 shortage, late arrival of generators, increased number of kits to prepare as a result of the shortage, and pharmacist working alone. Corrective actions involved reviewing procedures and discontinuing manual changes of inventory dispensed on prescription labels."
Louisiana incident number: LA090017
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 report was received from the State of Louisiana via facsimile:
"On July 9, 2009, a facility reported a mislabeled unit dose from GE Healthcare nuclear pharmacy. Three 20 mCi unit doses of Tc-99m MDP (bone scans) were ordered by Ochsner [a medical facility]. Two patients were injected. After viewing the images, it was determined that the unit doses were mislabeled. An investigation of GE Healthcare was performed. A preliminary cause was determined to be a mix up of MDP cold vial with DTPA [renal scans] as they closely resemble each other with the same vial configuration and same color label. Contributing factors leading to the incident were Tc-99m/Mo-99 shortage, late arrival of generators, increased number of kits to prepare as a result of the shortage, and pharmacist working alone. Corrective actions involved reviewing procedures and discontinuing manual changes of inventory dispensed on prescription labels."
Louisiana incident number: LA090017
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.
Other Nuclear Material
Event Number: 45194
Rep Org: ELK RUN COAL COMPANY
Licensee: ELK RUN COAL COMPANY
Region: 1
City: SYLVESTER State: WV
County:
License #: GL-700083
Agreement: N
Docket:
NRC Notified By: WILLIAM NEWSOME
HQ OPS Officer: HOWIE CROUCH
Licensee: ELK RUN COAL COMPANY
Region: 1
City: SYLVESTER State: WV
County:
License #: GL-700083
Agreement: N
Docket:
NRC Notified By: WILLIAM NEWSOME
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/10/2009
Notification Time: 20:03 [ET]
Event Date: 07/09/2009
Event Time: 10:00 [EDT]
Last Update Date: 07/10/2009
Notification Time: 20:03 [ET]
Event Date: 07/09/2009
Event Time: 10:00 [EDT]
Last Update Date: 07/10/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
GLENN DENTEL (R1DO)
BILL VONTILL (FSME)
GLENN DENTEL (R1DO)
BILL VONTILL (FSME)
LOSS OF CONTROL OF RADIOACTIVE DENSITY GAUGE
The licensee reported that they were informed by a scrap material yard that a load of material from their facility set off a radiation detector. The scrap yard Radiation Safety Officer (RSO) discovered that a piece of pipe had a density gauge still mounted on it. The scrap yard RSO obtained the proper permits and appropriately packaged the gauge and returned it to the licensee RSO. The source did not appear to be damaged and the leak test performed by the licensee RSO indicated no leakage. Through employee and contractor interviews, the licensee does not believe there were any personnel overexposures.
The Cs-137 source is a 7062 BP Kay-Ray that had an original source strength of 100 mCi. The estimated age of the source is 20 years so the current strength is in the 60-70 mCi range. The licensee has the source shielded and in secure storage awaiting shipment to the manufacturer (now Thermo-Electron) for proper disposal.
The licensee has been in contact with NRC Region 1 (Miller) over this incident.
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.
The licensee reported that they were informed by a scrap material yard that a load of material from their facility set off a radiation detector. The scrap yard Radiation Safety Officer (RSO) discovered that a piece of pipe had a density gauge still mounted on it. The scrap yard RSO obtained the proper permits and appropriately packaged the gauge and returned it to the licensee RSO. The source did not appear to be damaged and the leak test performed by the licensee RSO indicated no leakage. Through employee and contractor interviews, the licensee does not believe there were any personnel overexposures.
The Cs-137 source is a 7062 BP Kay-Ray that had an original source strength of 100 mCi. The estimated age of the source is 20 years so the current strength is in the 60-70 mCi range. The licensee has the source shielded and in secure storage awaiting shipment to the manufacturer (now Thermo-Electron) for proper disposal.
The licensee has been in contact with NRC Region 1 (Miller) over this incident.
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.