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Event Notification Report for June 29, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/28/2017 - 06/29/2017

** EVENT NUMBERS **


52807 52815 52816

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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
Notification Date: 06/15/2017
Notification Time: 15:26 [ET]
Event Date: 06/14/2017
Event Time: [YDT]
Last Update Date: 06/28/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

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.

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Agreement State Event Number: 52815
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: ATLAS ROOFING CORPORATION
Region: 4
City: DAINGERFIELD State: TX
County:
License #: 02416
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BETHANY CECERE
Notification Date: 06/20/2017
Notification Time: 11:51 [ET]
Event Date: 06/19/2017
Event Time: [CDT]
Last Update Date: 06/20/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER ON GAUGE

The following report was received by the State of Texas via email:

"On June 20, 2017, the Agency [Texas Department of State Health Services] was notified by the licensee that the shutter on a Thermo Fisher model SUP-1C gauge containing a 100 milliCurie source would not close. The gauge is located in a remote location at the facility and does not create an exposure risk to any individual. The manufacturer has been contacted and will be on site today, June 20, 2017, to repair the gauge. Additional information will be provided as it is received in accordance with SA-300."

The source is Cs-137. The gauge serial number is TG-564.

Texas Incident #: I 9495

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Agreement State Event Number: 52816
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: UNIVERSITY OF UTAH, RADIOLOGICAL HEALTH DEPT
Region: 4
City: WEST JORDAN State: UT
County:
License #: UT 1800231
Agreement: Y
Docket:
NRC Notified By: SPENCER WICKHAM
HQ OPS Officer: BETHANY CECERE
Notification Date: 06/21/2017
Notification Time: 13:51 [ET]
Event Date: 06/19/2017
Event Time: [MDT]
Last Update Date: 06/21/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED TO SITE ADJACENT TO INTENDED TARGET

The following State of Utah report was received by email:

"The licensee delivered a 500 cGy fraction of HDR [High Dose Rate] brachytherapy to a site adjacent to the intended target. This treatment was a supplemental boost to external beam radiotherapy, and the mistreated volume was included in the target volume of the external beam plan."

The State of Utah was notified of the event on June 21, 2017 by electronic mail opened at 1125 MDT.

Utah Event Report ID No: will be provided in follow up report.

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 Thursday, June 29, 2017
Thursday, June 29, 2017