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Event Notification Report for May 9, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/06/2016 - 05/09/2016

** EVENT NUMBERS **


51890 51893 51894

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Agreement State Event Number: 51890
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: ASARCO, THE MISSION UNIT
Region: 4
City: SAHARITA State: AZ
County:
License #: AZ 10-017
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/28/2016
Notification Time: 12:49 [ET]
Event Date: 04/23/2016
Event Time: [MST]
Last Update Date: 04/28/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ANGELA MCINTOSH (NMSS)

Event Text

AGREEMENT STATE REPORT - EMPLOYEES POTENTIALLY EXPOSED TO RADIATION

The following was received via email from Arizona:

"On April 26th, the Agency [Arizona Radiation Regulatory Agency] was contacted by the licensee who indicated that seventeen employees had been exposed to ionizing radiation by a nuclear gauge while working on Crusher Number Three. The nuclear gauge was mounted on the shoot above the crusher. The workers involved worked in the area of concern from Saturday April 23rd until Tuesday April 26th, when the Radiation Safety Officer was notified of the incident.

"The gauge involved is used for level detection in the shoot and contains 150 millicuries of Cesium-137. Radiation levels in the work area have yet to be determined.

"The investigation into this event is ongoing.

"The U.S. NRC and Arizona Governor's office are being notified of this event."

Arizona Incident number 16-006.

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Agreement State Event Number: 51893
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: MAYO CLINIC ARIZONA
Region: 4
City: PHOENIX State: AZ
County:
License #: AZ 07-448
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: DANIEL MILLS
Notification Date: 04/30/2016
Notification Time: 13:53 [ET]
Event Date: 04/27/2016
Event Time: [MST]
Last Update Date: 04/30/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE REPORT - IMPLANTED IODINE 125 SEED NOT ACCOUNTED FOR

The following was received from Arizona via email:

"On April 27th, the licensee [Mayo Clinic Arizona] discovered that one (1) I-125 seed was missing with an approximate activity of 0.3 millicuries. The breast tissue from a patient was analyzed by the licensees' surgical staff on April 26th and one seed was removed and then brought down to the nuclear medicine department on the morning of the 27th. The nuclear medicine staff quickly realized that there should have been two seeds, since two seeds were initially implanted. The licensee's radiation safety staff surveyed both the hospital surgical path area as well as the pathology/histology area and no source was discovered.

"The investigation into this event is ongoing.

"The U.S. NRC and Arizona Governor's office are being notified of this event."

Arizona Incident # 16-007

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: 51894
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: TUCSON MEDICAL CENTER
Region: 4
City: TUCSON State: AZ
County:
License #: AZ 10-010
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: DANIEL MILLS
Notification Date: 04/30/2016
Notification Time: 14:31 [ET]
Event Date: 04/29/2016
Event Time: [MST]
Last Update Date: 04/30/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following was received from Arizona via email:

"On April 29th, the licensee [Tucson Medical Center] discovered that a patient had received 37 percent more than the prescribed dose of Xofigo (Radium-223). The licensee had received two doses of Ra-223 for two patients the day prior. The technologist usually asks a patient their weight in order to re-calculate the dose, but forgot and accidently grabbed another Xofigo patient's dose on April 28th. The technologist realized the mistake when she went to inject the second patient on the 29th and the name on the patient's dose did not match the current patient's name. The prescribed dose was 86.7 microcuries and the actual administered dose was 119.3 microcuries.

"The investigation into this event is ongoing.

"The U.S. NRC and Arizona Governor's office are being notified of this event."

Arizona Incident # 16-008

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 Monday, May 09, 2016
Monday, May 09, 2016