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Event Notification Report for April 19, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/18/2016 - 04/19/2016

** EVENT NUMBERS **


51857 51858

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Agreement State Event Number: 51857
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: GEO-ADVANTEC, INC.
Region: 4
City: SAN DIMAS State: CA
County:
License #: 7949-19
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/08/2016
Notification Time: 13:10 [ET]
Event Date: 04/07/2016
Event Time: [PDT]
Last Update Date: 04/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following report was received from the State of California via email:

"On April 7, 2016, [the licensee gauge operator] for Geo-Advantec, Inc., contacted the California Office of Emergency Services to report a moisture density gauge, a CPN Model MC3 Elite (10 mCi Cs-137, 50 mCi Am:Be-241, S/N30625), was run over by an unknown type of vehicle. The incident occurred at 2003 Speyer Lane, Redondo Beach, CA. After taking the report, the report was forwarded to the Los Angeles County Radiation Management which was then forwarded to Brea office of Radiologic Health Branch (RHB).

"[The licensee gauge operator] was contacted by a RHB inspector and stated that the gauge had been run over and that the source rod had been broken. He was also asked if the Cs-137 source had been exposed, and he stated that he was taking a standard count and that the source was in the shielded position at the time of the incident. [The licensee gauge operator] was then asked to take pictures of the gauge so that it could be evaluated to determine if the sources were still intact and to determine the extent of the damage to the gauge. The pictures indicated that the source rod was broken approximately 1-2 inches below the bottom of the guide tube, which had broken off the source shield, and that the rest of the source rod appeared to be inside the opening on the top part of the source shield. The Am:Be-241 source appeared to be intact and still attached to the body of gauge. [The licensee gauge operator] was instructed to place the body of the gauge into the transport case in its normal position and then place the rest of the pieces of the gauge into the case. He was also instructed to lock the case and secure it into the transport vehicle as normal. He was then instructed to check ground below the gauge to verify that the source was not exposed during the incident. After [the licensee gauge operator] verified that there were no signs of the source having been extended during the incident, he was instructed to mark the area where the gauge was damaged to ensure that area could be found if a survey was needed and then he was allowed to transport the gauge to Maurer Technical Services (MTS) to be inspected and surveyed to ensure the sources were still in the gauge and to verify they were intact.

"When the gauge arrived at Maurer Technical Services, a survey was performed by the MTS RSO [Radiation Safety Officer] (meter type not reported). The gauge had contact reading of 8.5 mR/hr, which was consistent with a CPN MC3 moisture/density gauge with both sources in their shielded positon. The RSO also took swipes of the device, the hands of the operator and the trunk of the operator's car. An RHB inspector arrived at MTS to perform a count of the swipes with a Ludlum general purpose meter and a 44-9 Geiger-Mueller probe and found all of the swipes were at background, indicating that there was not leakage and the sources were intact. The gauge will be stored at MTS until disposal of the gauge can be arranged.

"The investigation is on-going and any citations will be determined at a later date."

CA 5010 # 040716.

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Agreement State Event Number: 51858
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: GEISINGER MEDICAL CENTER
Region: 1
City: DANVILLE State: PA
County:
License #: PA-0006
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/08/2016
Notification Time: 14:22 [ET]
Event Date: 04/13/2015
Event Time: [EDT]
Last Update Date: 04/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - INCORRECT DOSE PRESCRIBED BUT CORRECT DOSE ADMINISTERED

The following report was received from the Commonwealth of Pennsylvania via email:

"Notifications: The Licensee notified the Department April 1, 2016 of an event that occurred on April 13, 2015. It was discovered almost a year later upon routine review of written directives at the hospital. It is reportable under 10 CFR 35.3045.

"Event Description: A Xofigor patient was scheduled for their 6th and final treatment on April 13, 2015. The Authorized User (AU) prescribed 0.98 millicurie (mCi) on the written directive (WD). On the prescription form from the radiopharmacy, the 'dispensed amount' of Ra-223 was labeled as 99.40 microCuries (or 0.0994 mCi). The Nuclear Medicine Technologist measured '0.099 mCi' in the dose calibrator just before injecting the Xofigor into the patient (intravenously). The technologist failed to observe that the AU prescribed an activity of 0.98 mCi making the percent error between the measured vs. prescribed activity at -89.9% based upon what was documented in the WD. The hospital believes the intent of the AU was to prescribe '0.098 mCi' which is a typical dose; however, they cannot directly confirm that with the AU since the AU is no longer employed by Geisinger Health System. Another Geisinger AU who is qualified to prescribe Xofigor confirmed that 0.098 mCi would be the correct amount when calculated from the patient's weight. Consequently, if the intent was to prescribe 0.098 milliCuries, there would be no expected harm to the patient as they received the proper Xofigor activity.

"Cause of the event: Human error.

"Actions: None at this time. The licensee will submit a final report which will provide corrective actions. Notifying the patient would serve no beneficial purpose."

PA Report #: PA160012

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 Tuesday, April 19, 2016
Tuesday, April 19, 2016