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Event Notification Report for April 26, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/25/2018 - 04/26/2018

** EVENT NUMBERS **


53330 53343 53344

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Agreement State Event Number: 53330
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: WILCO NDT
Region: 4
City: NEEDVILLE State: TX
County:
License #: L06916
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/13/2018
Notification Time: 11:44 [ET]
Event Date: 04/12/2018
Event Time: [CDT]
Last Update Date: 04/25/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

TEXAS AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA PIGTAIL CONNECTOR FAILED

The following information was obtained from the state of Texas via email:

"On April 13, 2018, the Agency [Texas Department of State Health Services] received notice that a radiography camera had an equipment failure yesterday, April 12, 2018. The radiography crew was on a temporary jobsite and was setting up for a job. When the radiographer tried to connect the guide tube, the pigtail on the cable broke and the camera/cable was unusable. The radiographer contacted his radiation safety officer who informed the crew to bring the camera back to the office. The source did not leave the camera. No exposure to an individual occurred. The camera was a Spec-150, #2489 with an Iridium-192 source, G60 -VC1403 at 80 Curies. The manufacturer will be sent the equipment and a full report will be provided by the radiation safety officer within the next few days. Updates will be provide as received in accordance with SA300."

Texas Incident #9558

* * * UPDATE ON 04/25/2018 AT 1103 EST FROM ART TUCKER TO STEVEN VITTO * * *

"The Agency contacted the licensee and the licensee stated the connector on the source pig tail had separated from the pig tail. The licensee stated the manufacturer is currently inspecting the equipment. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO(Vasquez) and NMSS Events Notification via email.

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Non-Agreement State Event Number: 53343
Rep Org: PROVIDENCE HOSPITAL
Licensee: PROVIDENCE HOSPITAL
Region: 3
City: SOUTHFIELD State: MI
County:
License #: 21-280203
Agreement: N
Docket:
NRC Notified By: MICHELLE KRITZMAN
HQ OPS Officer: JEFF HERRERA
Notification Date: 04/18/2018
Notification Time: 13:14 [ET]
Event Date: 04/17/2018
Event Time: [EDT]
Last Update Date: 04/18/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
KENNETH RIEMER (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

WRITTEN DIRECTIVE FOR RA-223 ADMINISTRATION INCORRECT

A quarterly review conducted on 4/17/18, identified that the written directive for administration of Ra-223 was incorrect. The written directive stated that the Ra-223 should be administered orally, but should have stated that it was to be administered intravenously (IV). The review determined that there was no impact to any patients as a result of the error in the written directive. The review identified one case where the written directive was used. However, the technician administered the Ra-223 to the patient via IV and not orally.

The corrective actions taken by the licensee were to correct the written directive, and review the directive with the technician to understand why the technician did not consult with the physician when there was an error in the directive.

The licensee notified the NRC R3 Office (Warren).

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: 53344
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: VIRGINIA MASON MEDICAL CENTER
Region: 4
City: Seattle State: WA
County:
License #: WN-M048-1
Agreement: Y
Docket:
NRC Notified By: TRISTAN HAY
HQ OPS Officer: STEVEN VITTO
Notification Date: 04/18/2018
Notification Time: 13:50 [ET]
Event Date: 03/30/2018
Event Time: [PDT]
Last Update Date: 04/18/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

MISADMINISTRATION OF SIR-SPHERES Y-90 MICROSPHERES RESULTING IN AN UNDERDOSE

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

"Patient was under treated with Y-90 SIR-Spheres Microspheres. Prescribed dose was 24.59 mCi. Patient was treated with 8.9 mCi.

"Background: SIR-Spheres Microspheres Activity Calculator determined a treatment dose of 0.91 GBq (24.59 mCi). Written Directive was signed for 0.91 GBq. Prescribed dose was entered into the Treatment Worksheet as 0.91 mCi. Dose activity delivered to the interventional radiology procedure room (Dose In-Vial) was recorded as 0.96 mCi.

"Analysis: Radioactivity units of measurement varied between Written Directive and Treatment Worksheet. Radioactivity activity readings from the dose calibrator were recorded with a systematic error. Calibrator reading multiplication factor(x10) was not applied. Therefore, the vial pre-dispense Y-90 activity reading of 8.62 mCi should have been recorded as 86.2 mCi. Dose activity delivered to the IR procedure room was in fact 9.60 mCi rather than 0.96 mCi.

"Y-90 SIR-Spheres treatment on 3/30/2018 was incomplete because the prescribed 0.91 GBq prescribed dose was not administered. Standard post-procedure verification check identified the under treatment. The patient was informed by the prescribing physician and scheduled for a second treatment on 4/6/2018. The second Y-90 SIR-Spheres treatment was performed on 4/6/2018 and the remaining dose was administered to complete administration of the prescribed 0.91 GBq."

Washington State Incident Number: WA-18-010.

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, April 26, 2018
Thursday, April 26, 2018