Event Notification Report for September 26, 2014

RELEASE OF KRYPTON -85

The licensee received 125 millicuries of Krypton-85 in a cylinder that was in excess of their license limit. The license limit is 5 millicuries. During an experiment to transfer the Krypton-85 to an evacuation chamber, the chamber did not pressurize as expected, and all 125 millicuries of Krypton-85 was evacuated to atmosphere. The licensee is still investigating the incident and will provide additional information when it becomes available.

* * * UPDATE PROVIDED BY JOSEPH KOCH TO JEFF ROTTON AT 0835 ON 10/07/2014 * * *

Licensee provided correction to the original report. Event date was 09/26/2014 at 1600 CDT.

Notified R3DO (Orlikowski), FSME (McIntosh) and FSME Events Resource via email.

PRESCRIBED DOSAGE INCORRECTLY WRITTEN

"This is a notification, pursuant to 10 CFR 35.3045(a)(1), of a medical event that occurred on September 26, 2014, at the VA Palo Alto Health Care System, Palo Alto, California.

"On September 26, 2014, a dosage of about 110 microCuries (æCi) of radium-223 dichloride was administered to a patient. The prescribed dosage on the written directive was incorrectly written by the authorized user physician as 113.8 milliCuries (mCi). The basis for identifying this as a medical event is that the administered dosage differed from the prescribed dosage, as written on the written directive, by more than 20 percent. The authorized user physician was interviewed and stated that the intended prescription for injection was 113.8 æCi of radium-223 dichloride. Another authorized user physician, the Chief, Nuclear Medicine Service, who administered the dosage, confirmed that this was an appropriate dosage for this patient. No harm to the patient is expected since the treatment was successfully performed with the administration of a dosage nearly identical to the intended dosage. The medical event was discovered October 5, 2016, during an unannounced inspection of this facility conducted by the National Health Physics Program (NHPP). The permittee is required to submit a written report to NHPP within 15 days of discovery. NHPP will, in turn submit the report to NRC per regulatory requirements. The NHPP inspection is ongoing to determine overall compliance with 10 CFR 35.40, 10 CFR 35.41, and 10 CFR 35.3045."

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.