Event Notification Report for January 14, 2010
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/13/2010 - 01/14/2010
General Information or Other
Event Number: 45632
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: JEFF ZELL CONSULTING INC
Region: 1
City: CORAOPOLIS State: PA
County:
License #: 37-28531-01
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: CHARLES TEAL
Licensee: JEFF ZELL CONSULTING INC
Region: 1
City: CORAOPOLIS State: PA
County:
License #: 37-28531-01
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: CHARLES TEAL
Notification Date: 01/14/2010
Notification Time: 19:28 [ET]
Event Date: 01/14/2010
Event Time: 14:45 [EST]
Last Update Date: 01/14/2010
Notification Time: 19:28 [ET]
Event Date: 01/14/2010
Event Time: 14:45 [EST]
Last Update Date: 01/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
ROBERT LEWIS (FSME)
ILTAB via email
Canada via fax
ANTHONY DIMITRIADIS (R1DO)
ROBERT LEWIS (FSME)
ILTAB via email
Canada via fax
AGREEMENT STATE - MISSING MOISTURE DENSITY GAUGE
"Zell's former consultant HP (Health Physicist) informed DEP (Department of Environmental Protection) that [a] nuclear gauge was discovered [to be missing] while performing a 6-month inventory on January 13. An unsuccessful search for the missing nuclear density gauge (Humboldt Model 5001 EZ122; Ser. No. 5375) was concluded on January 14. The licensee notes the gauge cannot be accounted for at this time. Gauge contains about 10 milliCuries Cs-137 and 40 milliCuries Am-241 (as an Am/be neutron source)."
PA Event #: PA100001
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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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.
"Zell's former consultant HP (Health Physicist) informed DEP (Department of Environmental Protection) that [a] nuclear gauge was discovered [to be missing] while performing a 6-month inventory on January 13. An unsuccessful search for the missing nuclear density gauge (Humboldt Model 5001 EZ122; Ser. No. 5375) was concluded on January 14. The licensee notes the gauge cannot be accounted for at this time. Gauge contains about 10 milliCuries Cs-137 and 40 milliCuries Am-241 (as an Am/be neutron source)."
PA Event #: PA100001
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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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.
Hospital
Event Number: 45630
Rep Org: QHG OF INDIANA
Licensee: QHG OF INDIANA
Region: 3
City: FORT WAYNE State: IN
County:
License #: 13-01535-01
Agreement: N
Docket:
NRC Notified By: THOMAS M. KUMPURIS
HQ OPS Officer: JOE O'HARA
Licensee: QHG OF INDIANA
Region: 3
City: FORT WAYNE State: IN
County:
License #: 13-01535-01
Agreement: N
Docket:
NRC Notified By: THOMAS M. KUMPURIS
HQ OPS Officer: JOE O'HARA
Notification Date: 01/14/2010
Notification Time: 16:00 [ET]
Event Date: 01/14/2010
Event Time: 14:00 [EST]
Last Update Date: 01/14/2010
Notification Time: 16:00 [ET]
Event Date: 01/14/2010
Event Time: 14:00 [EST]
Last Update Date: 01/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
CHRISTINE LIPA (R3DO)
ROBERT LEWIS (FSME)
CHRISTINE LIPA (R3DO)
ROBERT LEWIS (FSME)
INCORRECT DOSE ADMINISTERED TO PATIENT
Two patients were to receive hyper thyroid therapy on 1/14/10, and the hospital prepared written directives for each patient. One patient was prescribed 25 milliCurie of I-131. The second patient was prescribed 30 milliCurie of I-131. The first patient arrived and the technician assayed and administered the 30 milliCurie dose for the patient who was to receive 25 milliCurie. The tech administered 31.4 milliCurie to the patient. This is a 25.6% difference than prescribed in the written directive for the patient. The patient and prescribing physician have not been informed. The hospital does not believe there is any long term medical consequence to the patient. The hospital management team is reviewing protocols to prevent recurrence of this event.
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.
Two patients were to receive hyper thyroid therapy on 1/14/10, and the hospital prepared written directives for each patient. One patient was prescribed 25 milliCurie of I-131. The second patient was prescribed 30 milliCurie of I-131. The first patient arrived and the technician assayed and administered the 30 milliCurie dose for the patient who was to receive 25 milliCurie. The tech administered 31.4 milliCurie to the patient. This is a 25.6% difference than prescribed in the written directive for the patient. The patient and prescribing physician have not been informed. The hospital does not believe there is any long term medical consequence to the patient. The hospital management team is reviewing protocols to prevent recurrence of this event.
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.