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Event Notification Report for June 3, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/02/2014 - 06/03/2014

** EVENT NUMBERS **


50135 50137 50139 50163

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Agreement State Event Number: 50135
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: NEBRASKA METHODIST HOSPITAL
Region: 4
City: LINCOLN State: NE
County:
License #: 01-07-02
Agreement: Y
Docket:
NRC Notified By: HOWARD SHUMAN
HQ OPS Officer: DANIEL MILLS
Notification Date: 05/23/2014
Notification Time: 16:05 [ET]
Event Date: 05/22/2014
Event Time: [CDT]
Last Update Date: 05/23/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT OVEREXPOSURE DUE TO MISCALCULATION

The following was received from the State of Nebraska via fax:

"At 1430 CDT, the RSO from Nebraska Methodist Hospital called to report a possible overexposure to a patient who had received a prostate treatment of implanted lodine-125 seeds. The RSO, who was also the Medical Physicist on the case, stated that he had mistakenly used the millicurie value for the air kerma value. The treatment dose was intended to be 145 Gray (14,500 rad) but the implant dose was calculated to be 178 Gray (17,800 rad) so the dose differentiated by 27 percent. It is unknown if the target organ (rectum) will exceed 50 rem."

Nebraska Item Number: NE140004

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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Agreement State Event Number: 50137
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: ST JOSEPHS HOSPITAL AND MEDICAL CENTER
Region: 4
City: PHOENIX State: AZ
County:
License #: 07-024
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: CHARLES TEAL
Notification Date: 05/23/2014
Notification Time: 17:19 [ET]
Event Date: 04/04/2014
Event Time: [MST]
Last Update Date: 05/23/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
FSME EVENTS RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED LESS THAN PRESCRIBED DOSE

The following was received from the State of Arizona via email:

"On May 22, 2014, the Agency was notified of a medical event that occurred on April 4, 2014 involving Y-90 labeled SIR Spheres.

"On April 4, 2014, an adult liver tumor patient was treated with an injection of SIR Spheres. The patient was prescribed 59.4 Gy to the liver, but instead, the actual dose to the liver was approximately 39 Gy. It was determined that the error occurred in the step of transferring the dose from the delivery vial to the dosing vial. The step of drawing up the sterile fluid was inadvertently omitted by the nuclear medicine technologist working alone which led to much less than the expected activity/sphere being transferred to the dosing vial. Only after the completion of the procedure was the large amount of residual activity detected and noted. The physicians noted that physiologic factors can affect the amount of spheres reaching the tumor so the discrepancy of the dose delivered apparently was not alarming or significant to them. The RSO discovered the medical event during a records review and recognized that the patient only received 63% of the prescribed dose."

Arizona First Notice Number: 14-013

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Agreement State Event Number: 50139
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: CORRADINO GROUP
Region: 1
City: MIAMI State: FL
County:
License #: 2770-1
Agreement: Y
Docket:
NRC Notified By: DAVID PIESKI
HQ OPS Officer: DANIEL MILLS
Notification Date: 05/24/2014
Notification Time: 18:28 [ET]
Event Date: 05/24/2014
Event Time: [EDT]
Last Update Date: 05/24/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (E-MA)

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

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

The following was received from the State of Florida:

A Troxler moisture density gauge, Model 3430 (Serial #39376), was stolen from a locked trailer located at the 36th Street Bridge Project.

Additional information will be provided when it is available.

Florida Event Number: FL14-045

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

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Power Reactor Event Number: 50163
Facility: VOGTLE
Region: 2 State: GA
Unit: [3] [4] [ ]
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: MICHAEL YOX
HQ OPS Officer: CHARLES TEAL
Notification Date: 06/02/2014
Notification Time: 16:47 [ET]
Event Date: 06/02/2014
Event Time: 07:52 [EDT]
Last Update Date: 06/02/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
EUGENE GUTHRIE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Under Construction 0 Under Construction
4 N N 0 Under Construction 0 Under Construction

Event Text

NON-LICENSED CONTRACT EMPLOYEE SUPERVISOR IN VIOLATION OF FITNESS FOR DUTY POLICY

A non-licensed contract employee supervisor had a confirmed positive result for a controlled substance. The employee's access to the plant has been terminated.

The licensee has notified the NRC Senior Resident Inspector.

Page Last Reviewed/Updated Tuesday, June 03, 2014
Tuesday, June 03, 2014