Event Notification Report for October 13, 2016
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/12/2016 - 10/13/2016
Agreement State
Event Number: 52311
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: THE NEBRASKA MEDICAL CENTER
Region: 4
City: OMAHA State: NE
County:
License #: 01-88-01
Agreement: Y
Docket:
NRC Notified By: BRYAN MILLER
HQ OPS Officer: STEVE SANDIN
Licensee: THE NEBRASKA MEDICAL CENTER
Region: 4
City: OMAHA State: NE
County:
License #: 01-88-01
Agreement: Y
Docket:
NRC Notified By: BRYAN MILLER
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/20/2016
Notification Time: 15:16 [ET]
Event Date: 10/13/2016
Event Time: 00:00 [CDT]
Last Update Date: 12/15/2016
Notification Time: 15:16 [ET]
Event Date: 10/13/2016
Event Time: 00:00 [CDT]
Last Update Date: 12/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JOHN KRAMER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
JOHN KRAMER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - DIAGNOSTIC RADIOACTIVE SOURCE MISSING
On the morning of 10/13/16, a patient received a diagnostic 0.297 mCi I-125 seed implant to characterize a breast lesion. That afternoon, the tissue and implanted seed were removed and sent to pathology for assessment. The bio-waste was received in pathology as a non-radioactive sample contrary to hospital procedures. A subsequent search of the pathology lab could not locate the missing source.
The State of Nebraska was notified of the incident on 10/19/16.
* * * UPDATE ON 12/15/16 AT 0958 EST FROM BRYAN MILLER TO DONG PARK * * *
The following was received from the State of Nebraska via email:
"A Radioactive Seed Localization (RSL) procedure was performed on Thursday October 13, 2016, and contrary to procedures, the seed was sent to Pathology without an escort from the radiation safety office. Since there was no presence from radiation safety, pathology treated the excised sample as non-radioactive. It was not until the next day on Friday, the Thursday's RSL procedure was made known to the Radiation Safety Office. During Friday's procedure, the CNMT inquired why the paperwork from the Thursday's procedures was not picked up. This alerted Radiation Safety that a seed was sent to pathology without their presence to retrieve the seed and that there may be a misplaced seed. With the help from a radiologist, Radiation Safety reviewed the x-ray from the excised tissue to ensure the seed was removed from the patient. The x-ray did in fact indicate the seed was removed from the patient. Since the tissue is sent to the pathology lab, Radiation Safety surveyed the pathology lab and it's personnel intensively. They source could not be found. Radiation Safety has two theories where the source may have ended up. Down the sink or in a 20 gallon biological waste container. The Licensee is changing the name of the lumpectomy procedure to make a clear distinction between a non-radioactive lumpectomy and a lumpectomy that includes a radioactive material source. This will alert the staff that the radioactive seed needs to have Radiation Safety escort the seed to pathology. It will also alert the pathology staff of the radioactive seed and to ensure to locate and separate the seed from the sample prior to dissecting the tissue. Another precaution is that the mammography tech is going to label the sample container/slide with a 'Caution, Radioactive Materials' label to confirm the seed has been found and to also alert the pathology staff of the presence of the radioactive seed. Training of these changes has been performed and Radiation Safety will keep a close watch on the next procedures to ensure the new procedure has been implemented."
Item Number: NE160001
Notified R4DO (Kellar) and NMSS Events Notification 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
On the morning of 10/13/16, a patient received a diagnostic 0.297 mCi I-125 seed implant to characterize a breast lesion. That afternoon, the tissue and implanted seed were removed and sent to pathology for assessment. The bio-waste was received in pathology as a non-radioactive sample contrary to hospital procedures. A subsequent search of the pathology lab could not locate the missing source.
The State of Nebraska was notified of the incident on 10/19/16.
* * * UPDATE ON 12/15/16 AT 0958 EST FROM BRYAN MILLER TO DONG PARK * * *
The following was received from the State of Nebraska via email:
"A Radioactive Seed Localization (RSL) procedure was performed on Thursday October 13, 2016, and contrary to procedures, the seed was sent to Pathology without an escort from the radiation safety office. Since there was no presence from radiation safety, pathology treated the excised sample as non-radioactive. It was not until the next day on Friday, the Thursday's RSL procedure was made known to the Radiation Safety Office. During Friday's procedure, the CNMT inquired why the paperwork from the Thursday's procedures was not picked up. This alerted Radiation Safety that a seed was sent to pathology without their presence to retrieve the seed and that there may be a misplaced seed. With the help from a radiologist, Radiation Safety reviewed the x-ray from the excised tissue to ensure the seed was removed from the patient. The x-ray did in fact indicate the seed was removed from the patient. Since the tissue is sent to the pathology lab, Radiation Safety surveyed the pathology lab and it's personnel intensively. They source could not be found. Radiation Safety has two theories where the source may have ended up. Down the sink or in a 20 gallon biological waste container. The Licensee is changing the name of the lumpectomy procedure to make a clear distinction between a non-radioactive lumpectomy and a lumpectomy that includes a radioactive material source. This will alert the staff that the radioactive seed needs to have Radiation Safety escort the seed to pathology. It will also alert the pathology staff of the radioactive seed and to ensure to locate and separate the seed from the sample prior to dissecting the tissue. Another precaution is that the mammography tech is going to label the sample container/slide with a 'Caution, Radioactive Materials' label to confirm the seed has been found and to also alert the pathology staff of the presence of the radioactive seed. Training of these changes has been performed and Radiation Safety will keep a close watch on the next procedures to ensure the new procedure has been implemented."
Item Number: NE160001
Notified R4DO (Kellar) and NMSS Events Notification 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
Non-Agreement State
Event Number: 52296
Rep Org: BAYER CORPSCIENCE LP
Licensee: BAYER CORPSCIENCE LP
Region: 3
City: KANSAS CITY State: MO
County:
License #: 24-03830-01
Agreement: N
Docket:
NRC Notified By: STEVEN SCHERICH
HQ OPS Officer: DONG HWA PARK
Licensee: BAYER CORPSCIENCE LP
Region: 3
City: KANSAS CITY State: MO
County:
License #: 24-03830-01
Agreement: N
Docket:
NRC Notified By: STEVEN SCHERICH
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/14/2016
Notification Time: 14:17 [ET]
Event Date: 10/13/2016
Event Time: 15:00 [CDT]
Last Update Date: 10/14/2016
Notification Time: 14:17 [ET]
Event Date: 10/13/2016
Event Time: 15:00 [CDT]
Last Update Date: 10/14/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
RICHARD SKOKOWSKI (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
STUCK SHUTTER ON A DENSITY GAUGE
The licensee Radiation Safety Officer (RSO) determined that the shutter to a Berthold Model LB7442 gauge with a 1 Ci Cs-137 source (serial number: 012\06) did not shut during biannual maintenance checks. Personnel is informed about the gauge with proper signage, and the RSO does not believe any exposure to personnel occurred, because the shutter is normally in the open position. A licensed Berthold technician has been contacted and will come to the site to repair the gauge.
The licensee notified NRC Region 3 (Nieves).
The licensee Radiation Safety Officer (RSO) determined that the shutter to a Berthold Model LB7442 gauge with a 1 Ci Cs-137 source (serial number: 012\06) did not shut during biannual maintenance checks. Personnel is informed about the gauge with proper signage, and the RSO does not believe any exposure to personnel occurred, because the shutter is normally in the open position. A licensed Berthold technician has been contacted and will come to the site to repair the gauge.
The licensee notified NRC Region 3 (Nieves).