Event Notification Report for June 14, 2017
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/13/2017 - 06/14/2017
Agreement State
Event Number: 52809
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: KENVIRONS, INC.
Region: 1
City: FRANKFORT State: KY
County:
License #: 401-079-20
Agreement: Y
Docket:
NRC Notified By: CURT PENDERGRASS
HQ OPS Officer: BETHANY CECERE
Licensee: KENVIRONS, INC.
Region: 1
City: FRANKFORT State: KY
County:
License #: 401-079-20
Agreement: Y
Docket:
NRC Notified By: CURT PENDERGRASS
HQ OPS Officer: BETHANY CECERE
Notification Date: 06/16/2017
Notification Time: 09:01 [ET]
Event Date: 06/14/2017
Event Time: 00:00 [CDT]
Last Update Date: 06/16/2017
Notification Time: 09:01 [ET]
Event Date: 06/14/2017
Event Time: 00:00 [CDT]
Last Update Date: 06/16/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - LOSS OF CONTROL OF LICENSED MATERIAL
The following was received from the Commonwealth of Kentucky:
"Sometime in February 2009 during the decommissioning of the licensee's laboratory, the electron capture detector (ECD) contained in a Varian model 3700 gas chromatograph went missing. The ECD was an Amersham model NBC containing 8 mCi of Ni-63, S/N A404, assay date 2/14/1992. The licensee discovered the device was missing during a routine inspection by the KY Radiation Health Branch. This event is actively being investigated by the licensee."
KY Event Report ID No: KY170005
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
The following was received from the Commonwealth of Kentucky:
"Sometime in February 2009 during the decommissioning of the licensee's laboratory, the electron capture detector (ECD) contained in a Varian model 3700 gas chromatograph went missing. The ECD was an Amersham model NBC containing 8 mCi of Ni-63, S/N A404, assay date 2/14/1992. The licensee discovered the device was missing during a routine inspection by the KY Radiation Health Branch. This event is actively being investigated by the licensee."
KY Event Report ID No: KY170005
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: 52807
Rep Org: PROVIDENCE ALASKA MEDICAL CENTER
Licensee: PROVIDENCE ALASKA MEDICAL CENTER
Region: 4
City: ANCHORAGE State: AK
County:
License #: 50-17838-01
Agreement: N
Docket:
NRC Notified By: YONGLI NING
HQ OPS Officer: STEVE SANDIN
Licensee: PROVIDENCE ALASKA MEDICAL CENTER
Region: 4
City: ANCHORAGE State: AK
County:
License #: 50-17838-01
Agreement: N
Docket:
NRC Notified By: YONGLI NING
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/15/2017
Notification Time: 15:26 [ET]
Event Date: 06/14/2017
Event Time: 00:00 [YDT]
Last Update Date: 06/28/2017
Notification Time: 15:26 [ET]
Event Date: 06/14/2017
Event Time: 00:00 [YDT]
Last Update Date: 06/28/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
VIVIAN CAMPBELL (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
PATIENT RECEIVED A HIGHER DOSE THAN PRESCRIBED
On 6/14/17 a patient undergoing treatment using Sir-Spheres (Y-90) received a dose of 540 Gray instead of the 110 Gray prescribed. This occurred due to a calibration error. The prescribing physician discussed the error with the patient who was released and returned home. The Radiation Safety Officer (RSO) is investigating the incident. No adverse effect to the patient has been observed to date.
* * * UPDATE PROVIDED BY YONGLI NING TO JEFF ROTTON AT 1816 EDT ON 06/28/2017 * * *
The original report is being updated to reflect that the dose information provided initially was for the liver (prescribed organ). Thera-Spheres were used in the procedure versus the Sir-Spheres as stated in the original report. The licensee also provided received dose information for the lung of 25.76 Gray from the event described above.
Notified the R4DO (Kellar) and NMSS Events Notification group via email.
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.
On 6/14/17 a patient undergoing treatment using Sir-Spheres (Y-90) received a dose of 540 Gray instead of the 110 Gray prescribed. This occurred due to a calibration error. The prescribing physician discussed the error with the patient who was released and returned home. The Radiation Safety Officer (RSO) is investigating the incident. No adverse effect to the patient has been observed to date.
* * * UPDATE PROVIDED BY YONGLI NING TO JEFF ROTTON AT 1816 EDT ON 06/28/2017 * * *
The original report is being updated to reflect that the dose information provided initially was for the liver (prescribed organ). Thera-Spheres were used in the procedure versus the Sir-Spheres as stated in the original report. The licensee also provided received dose information for the lung of 25.76 Gray from the event described above.
Notified the R4DO (Kellar) and NMSS Events Notification group via email.
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.