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Event Notification Report for June 10, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/09/2016 - 06/10/2016

** EVENT NUMBERS **


51970 51971 51973

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Agreement State Event Number: 51970
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT PROVIDED
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JANAKI KRISHNAMOORTHY
HQ OPS Officer: JEFF HERRERA
Notification Date: 06/01/2016
Notification Time: 15:17 [ET]
Event Date: 05/24/2016
Event Time: [EDT]
Last Update Date: 06/01/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE TO THE LEFT LOBE OF LIVER

The following report was received from the New York State Department of Health, Bureau of Environmental Radiation Protection via facsimile:

"Radiation safety staff from a hospital called on 5/24/2016 to report a medical event that meets the reportability criterion on the borderline. 79.5 percent of intended dose is believed to have been delivered to the left lobe of the liver of a patient receiving Y90 treatment. The patient had received treatment to the right lobe a month ago. The left lobe was smaller with small vessels. The waste measured after the procedure showed that only about 79 .5 percent had been delivered. The licensee usually is able to administer 95 percent of intended dose in this procedure. We were informed that since the amount retained in the device is about the same, smaller doses tend to show a greater percent in retained in the device. They will send a report within 7 days."

NYS NRC Event Report ID No.: NYDOH-16-02
NY State Incident No.: 1146

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: 51971
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: CARDINAL HEALTH
Region: 4
City: DALLAS State: TX
County:
License #: 02048
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: JEFF HERRERA
Notification Date: 06/01/2016
Notification Time: 15:46 [ET]
Event Date: 06/01/2016
Event Time: [CDT]
Last Update Date: 06/01/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
CNSNS (MEXICO) (EMAI)

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

Event Text

AGREEMENT STATE REPORT - TWO RADIOACTIVE MATERIALS PACKAGES NOT LOCATED AFTER CARRIER ACCIDENT

The following report was received from the Texas Department of State Health Services via facsimile:

"On June 1, 2016, the licensee notified the Agency [Texas Department of State Health Services] that one of its shipments was involved in a transportation accident. A carrier was transporting two type A packages, each containing a vial of fluorodeoxyglucose (F-18), 10 mCi, when it was involved in an accident on an unreported freeway. Emergency responders arrived at the scene, the driver was taken to a hospital. The vehicle was cleared from the roadway. It is uncertain at this time where the vehicle or the packages are located. The licensee is obtaining information to recover the radioactive materials. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I 9408

* * * UPDATE AT 1703 EDT ON 6/1/16 FROM ART TUCKER TO JEFF HERRERA * * *

The following report was received from the Texas Department of State Health Services via email:

"Agency [Texas Department of State Health Services] received call 1529 CDT from licensee. He informed us [Texas] that the packages were intact, not damaged, and recovered from the accident vehicle. The packages are currently located at the original pharmacy location in Dallas. The vial activity amount was 15 mCi each instead of the reported 10 mCi. The licensee stated that since the driver was not his employee he could not obtain information on the driver.

"The packages were intact and no exposures occurred."

Notified the R4DO (Deese), NMSS Events, and Mexico (via email).

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

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Agreement State Event Number: 51973
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: LOMA LINDA MEDICAL CENTER
Region: 4
City: SAN BERNARDINO State: CA
County:
License #: 0060-36
Agreement: Y
Docket:
NRC Notified By: JOHN G. FASSELL
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/02/2016
Notification Time: 20:22 [ET]
Event Date: 05/27/2016
Event Time: [PDT]
Last Update Date: 06/02/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY UNDERDOSE

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

"The RSO [Radiation Safety Officer] of Loma Linda Medical Center notified the RHB [Radiologic Health Branch] Brea ICE [Inspection, Compliance and Enforcement] office that they believe a medical event occurred on Friday, May 28, 2016.

"A patient was admitted to the hospital for treatment of carcinoma. The treatment plan involved [10 CFR] 35.400 use of Cs-137 sealed sources for brachytherapy with a tandem and ovoid applicator. The patient's written directive called for 3,460 cGy to target area A (left side tandem), but only approximately 1,500 cGy was delivered. The lower rectum and vaginal areas received more than expected dose, but is believed to be within tolerance. Critical organs of bladder and mid-rectum also received less than expected incidental exposure.

"The cause of the under dose was human error. The applicator tube used to place the source into the tandem had become crimped by the lead pig during transport to the patients room. During application by the resident physician and medical physicist, the resistance felt during the application process lead them to believe the source was fully deployed to the end of the tube.

"The chief physicist notified the RSO on Tuesday, May 31, 2016 at 1630 pm, of his dose calculations, in which the hospital began medical event notifications."

5010 Number: 060216

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 Friday, June 10, 2016
Friday, June 10, 2016