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Event Notification Report for May 21, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/20/2015 - 05/21/2015

** EVENT NUMBERS **


51037 51069

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 51037
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: NOT PROVIDED
Region: 4
City: TEMPLE State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/04/2015
Notification Time: 11:46 [ET]
Event Date: 04/30/2015
Event Time: [CDT]
Last Update Date: 05/20/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICA ()

Event Text

AGREEMENT STATE REPORT - RUPTURED IODINE SEED DURING REMOVAL

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

"On May 4, 2015, licensee's Radiation Safety Officer (RSO) reported to the Agency [Texas Department of State Health Services] that he had been notified today that on Thursday, April 30, 2015, a physician had ruptured an I-125 seed during removal from a patient. The seed was used for localization in a breast treatment procedure. The seed activity was 357 microCuries at the time of treatment on 4/30/15. The seed was identified as leaking after removal and in a container in the pathology department. The physician had screened the patient with a probe in the tissue/lesion and no radioactivity was found. No overexposure to the patient or doctor had occurred. The RSO stated he was preparing a full detailed report. Further information will be provided in accordance with SA300 guidelines."

Texas Incident # I-9310

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.

* * * RETRACTION AT 1347 EDT ON 05/20/15 FROM KAREN BLANCHARD TO S. SANDIN VIA EMAIL * * *

This report is retracted based on the following:

"More complete information was obtained from the licensee. The seed covering was damaged by the physician during excision of tissue from patient. The patient was thoroughly checked following the excision (standard procedure) and there was no radiation detected. There was radioactivity detected in the excised tissue by pathology after seed was removed from the tissue. The licensee identified and remediated all contamination and managed processing of tissue to prevent further contamination. No aspect of the event met any reporting criteria. It has been determined this was not a reportable event."

Notified R4DO (Taylor) and NMSS Events Notification via email.

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Non-Agreement State Event Number: 51069
Rep Org: DEPARTMENT OF VETERANS AFFAIRS
Licensee: DEPARTMENT OF VETERANS AFFAIRS
Region: 4
City: SALT LAKE CITY State: UT
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: CRAIG ADAMS
HQ OPS Officer: DANIEL MILLS
Notification Date: 05/13/2015
Notification Time: 16:37 [ET]
Event Date: 02/24/2015
Event Time: [MDT]
Last Update Date: 05/13/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
HIRONORI PETERSON (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
MICHAEL VASQUEZ (R4DO)

Event Text

INCORRECT DOSE RECORDED ON PRESCRIPTION DIRECTIVE

"This is a notification, pursuant to 10 CFR 35.3045(a)(1), of a medical event that occurred at the VA Salt Lake City Health Care System, Salt Lake City, Utah.

"On February 24, 2015, a dosage of 30.8 millicuries of I-131 sodium iodide (capsule form) was administered to a patient for a thyroid ablation. The prescribed dosage on the written directive was incorrectly annotated as 3 millicuries.

"The basis for identifying this as a medical event is the administered dosage differed from the prescribed dosage, as annotated on the written directive, by more than 20 percent.

"The medical event was discovered today (May 13, 2015) during an inspection, conducted by the National Health Physics Program (NHPP).

"Interview of the Radiation Safety Officer revealed the standard dosage for a thyroid ablation is 30 millicuries of I-131 sodium iodide (capsule form). Interview of the authorized user (a physician) revealed the intended prescription was for 32 millicuries of I-131 sodium iodide (capsule form).

"No biological harm to the patient is expected since the thyroid ablation was successfully performed. The patient and attending physician were not informed of the incorrect annotation on the written directive since the thyroid ablation was successfully performed, as clinically intended, with a dosage of I-131 sodium iodide (capsule form) within an acceptable range of the authorized user's intent.

"The inspection is ongoing with causal factors and corrective actions being developed. Additional information will be provided in a 15-day written report, to be submitted to NRC Region III. National Health Physics Program notified NRC Region III (Patricia Pelke, Chief, Materials Licensing Branch Chief) of the medical event by telephone.

"The Department of Veterans Affairs holds NRC License No. 03-23853-01VA, a master materials license. Permits are issued under the license to Veterans Health Administration facilities. The VHA permit number for the facility involved in this medical event is 43-03299-01. National Health Physics Program makes required notifications to NRC. "

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.

Page Last Reviewed/Updated Thursday, May 21, 2015
Thursday, May 21, 2015