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Event Notification Report for March 1, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/29/2016 - 03/01/2016

** EVENT NUMBERS **


51744 51745 51746 51748

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Agreement State Event Number: 51744
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: INTERNATIONAL PAPER
Region: 1
City: GEORGETOWN State: SC
County:
License #: 060
Agreement: Y
Docket:
NRC Notified By: MARK WINDHAM
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/19/2016
Notification Time: 11:38 [ET]
Event Date: 02/18/2016
Event Time: 21:27 [EST]
Last Update Date: 02/19/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - TWO UNUSED PROCESS GAUGES SENT TO SCRAP YARD

International Paper performed an inventory of their sources and realized that while performing demolition work at their facility, two unused process gauges were removed from the site. The removal of the gauges was outside the scope of the demolition work. The two process gauges were located on long poles, were removed from the site using a crane, and were sent to a nearby scrap yard. The South Carolina Division of Health and Environmental Control sent an inspector to the scrap yard and he was able to find and recover both gauges. The shutter on one gauge had remained closed and the second gauge shutter was partially open and reading 50 mR/hour on contact. The first gauge was recovered at 1220 EST and the second gauge was recovered at 1315 EST and the shutter was shut. Wipe tests on both gauges were negative. The gauges were returned to International Paper and are locked in a secure location. No personnel exposures were expected from this incident.

Gauges:
Cs-137
50 mCi each (in 1988)
TN Tech Model 5219
Serial Numbers: TNB61 and TNB64

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Agreement State Event Number: 51745
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: 21ST CENTURY ONCOLOGY
Region: 1
City: PLANTATION State: FL
County:
License #: 2499-1
Agreement: Y
Docket:
NRC Notified By: KELLIE ANDERSON
HQ OPS Officer: STEVEN VITTO
Notification Date: 02/19/2016
Notification Time: 12:35 [ET]
Event Date: 08/27/2015
Event Time: [EST]
Last Update Date: 02/19/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL OVERDOSE

The following was received via email:

"On August 27th 2015, a patient with 21st [Century] Oncology who was prescribed a 67.13 mCi dose of Sm-153 received an 86.9 mCi dose. The resulting over dose was more than 29.5 [percent] of the prescribed dose. The error was discovered through discrepancies in their pharmacies inventory when a new order was created for a new patient.

"On Feb 15, 2016, [21st Century Oncology] were preparing an order for Sm-153 for a new patient. The nurse referred to the last administered Samarium case (August 27, 2015) for information on activity, patient weight and pricing. In order to clarify the relation between dosage and patient weight, he asked the physics staff to perform a second check of the records. When the requested check was done the following error was discovered.

"Upon re-evaluation of the treatment procedure, the physics staff determined that the dosage of 91 mCi received from the pharmacy was not correctly calculated for the patient weight that was specified on the original order. The pharmacy was then requested to fax back the original order (Form J). The fax which they sent confirmed the correct weight of the patient (148 lbs). For this weight a correct calculation would have indicated an activity of 67.13 mCi. Instead the pharmacy had shipped the (incorrect) activity of 91 mCi. The resulting delivered dosage was 29.5 [percent] more than the prescribed dose. Thus [the staff] concluded that a medical event had occurred.

"The Radiation Oncologist notified the referring physician on February 16, 2016. The Radiation Oncologist also will note this communication in the patient's chart."

Florida Incident Number: FL 16-029

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: 51746
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UF HEALTH SHANDS CANCER HOSPITAL
Region: 1
City: GAINESVILLE State: FL
County:
License #: 3157-1
Agreement: Y
Docket:
NRC Notified By: KELLIE ANDERSON
HQ OPS Officer: STEVEN VITTO
Notification Date: 02/19/2016
Notification Time: 17:06 [ET]
Event Date: 02/19/2016
Event Time: [EST]
Last Update Date: 02/19/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following was received via email:

"On February 19th, 2016, a patient was prescribed and administered a 1.87 GBq Yttrium-90 [Thera-Sphere] treatment. The patient only received 0.28 GBq. [There are] no details as to the cause of the misadministration. [The Radiation Safety Officer] will provide a detailed report next week."

Florida Incident # FL16-033

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: 51748
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: BASIC ENERGY SERVICES LP
Region: 4
City: EASTLAND State: TX
County:
License #: 06425
Agreement: Y
Docket:
NRC Notified By: GENTRY HEARN
HQ OPS Officer: DANIEL MILLS
Notification Date: 02/22/2016
Notification Time: 14:04 [ET]
Event Date: 02/18/2016
Event Time: [CST]
Last Update Date: 02/22/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
DENNIS ALLSTON (ILTA)

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

Event Text

AGREEMENT STATE REPORT - LOST DENSITY GAUGE

The following was received from Texas via email:

"On February 22, 2016, the Agency [Texas] received notice that while under reciprocity in Louisiana, the licensee had lost a Thermo Fisher model 5192 (sn B8191) with 200 milicuries of Cesium-137 (sn 5854CP). Exposure to the public is unlikely due to the design of the device. It is not known whether the device was lost or stolen. The Louisiana Department of Environmental Quality is conducting the investigation. Addition information will be provided as it is received in accordance with SA-300."

The device was lost in Louisiana but reported to Texas by a Texas licensee. The state of Texas notified the state of Louisiana and the NRC. Louisiana will conduct an investigation of the issue.

Texas Incident # I-9380

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

Page Last Reviewed/Updated Tuesday, March 01, 2016
Tuesday, March 01, 2016