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Event Notification Report for December 27, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/26/2017 - 12/27/2017

** EVENT NUMBERS **


53127 53129 53130

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Agreement State Event Number: 53127
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: UNIVERSITY OF CHICAGO HOSPITAL
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01678-02
Agreement: Y
Docket:
NRC Notified By: GIBB VINSON
HQ OPS Officer: VINCE KLCO
Notification Date: 12/19/2017
Notification Time: 17:05 [ET]
Event Date: 12/15/2017
Event Time: [CST]
Last Update Date: 12/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BILLY DICKSON (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE

The following information was received from the State of Illinois:

"The University of Chicago Medical Center reported an underdose of Y90 Theraspheres today [12/19/17] to a patient. 53.4 % of dose was delivered with 46.6% stuck in catheter. 21 mCi was ordered and 11.21 was delivered. CT scan verified dose administered in correct location. On 12/18/17, it was still undetermined why remaining dose hung up in catheter. Additional dose [is] being ordered to complete the therapy as a fractionated dose. The licensee is investigating why the catheter became blocked. A 15 day written report will follow."

Illinois Incident: IL177059

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: 53129
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: REYNOLDS, SMITH AND HILLS CS, INC
Region: 1
City: ORLANDO State: FL
County:
License #: 2732-2
Agreement: Y
Docket:
NRC Notified By: TIM DUNN
HQ OPS Officer: VINCE KLCO
Notification Date: 12/19/2017
Notification Time: 18:28 [ET]
Event Date: 11/14/2017
Event Time: [EST]
Last Update Date: 12/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN AND RETRIEVED TROXLER GAUGE

The following information was excerpted from an email received from the State of Florida:

The State of Florida received a notice on 11/15/17 that a Troxler Gauge and a company vehicle was stolen from the licensee by an employee. A City of Orlando Police report was issued (2017-442672). On 12/7/2017, a notice was received from the licensee to inform State of Florida Bureau of Radiation Control that the gauge was found intact and undamaged.

The Troxler moisture density gauge is a model number 3440; serial number 27931; Cs-137/AmBe; 8mCi/40mCi.

Florida Incident Number: FL17-298.

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

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: 53130
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: ZEVACOR
Region: 1
City: SANFORD State: FL
County:
License #: 3287-1
Agreement: Y
Docket:
NRC Notified By: TIM DUNN
HQ OPS Officer: VINCE KLCO
Notification Date: 12/19/2017
Notification Time: 17:40 [ET]
Event Date: 11/09/2017
Event Time: [EST]
Last Update Date: 12/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
GRETCHEN RIVERA-CAPE (NMSS)
PATRICIA MILLIGAN (INES)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVER-EXPOSURE

The following was excerpted from an email received from the State of Florida:

The State of Florida received a notice of an over-exposure from the licensee. An employee received a whole body dose of 5019 mR read on her dosimeter on 10/10/2017. The investigation determined that the most likely cause of the over-exposure was due to an unusual number of equipment failures with the synthesis units requiring employee intervention to correct the issues. Dose rates and doses to the employee were not being monitored real time. The employee has been retrained on the standard operating procedures. Alarming personal electronic dosimeters have been purchased and are in use to alert personnel of the radiation fields.

Florida Incident Number: FL17-299

Page Last Reviewed/Updated Wednesday, December 27, 2017
Wednesday, December 27, 2017