Event Notification Report for November 16, 2018

AGREEMENT STATE REPORT - MISADMINISTRATION OF SODIUM PERTECHNETATE

The following information was received via e-mail from the State of Florida:

"On Friday, November 16, 2018, [the licensee] called to report a medical event involving licensee 4000-1. A patient was administered 150 milliCi of Sodium Pertechnetate that was originally intended to be used to calibrate a machine. The critical organ dose was less than 50 rem; the effective dose was 7 rem."

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.

TROXLER GAUGE LOST IN TRANSIT

On 11/16/2018, a Troxler gauge was declared lost by the EPA while in transit from Ada, OK to the Troxler Corporation in Research Triangle Park, NC. The Troxler gauge departed from the EPA Office of Research and Development to the Troxler corporation for disposal on 11/8/2018. On 11/16/2018, the EPA Radiation Safety Officer contacted Troxler and determined that they had not yet received the gauge. The transportation company was then contacted and the transportation company records indicated that the gauge was still in transit to Memphis, TN, but could not be located. The EPA is still investigating to determine the location of the gauge. The gauge is a Troxler Model 4302, Serial Number 382, containing 10 milliCuries of Am-241/Be.

* * * RETRACTION ON 11/21/18 AT 0959 EST FROM CHERRI ADAIR TO BETHANY CECERE * * *

The intact gauge was located in Richmond, VA. The transportation company plans to deliver the gauge to Troxler, as originally intended.

Notified R4DO (Werner), NMSS Events Notification Group, and ILTAB by 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

TRANSPORT OF POTENTIALLY CONTAMINATED WORKER AND SUBSEQUENT FATALITY

"On November 16, 2018 at 0202 EST, a potentially contaminated Dominion worker was transported offsite for medical attention. The individual was initially found unresponsive in a contaminated area. A partial survey was performed prior to the individual being transported offsite, and no contamination was found. The individual passed away in transit to the hospital. Follow-up surveys to verify no contamination are ongoing. A notification to OSHA (Occupational Safety and Health Administration) is planned.

"This event is being reported pursuant to 10CFR50.72(b)(2)(xi) due to notification of an offsite organization and 10CFR50.72(b)(3)(xii) due to a potentially contaminated worker transported offsite.

"The NRC Resident Inspector was notified."


* * * UPDATE FROM ALAN BIALOWAS TO DONALD NORWOOD AT 1640 EST ON 11/16/2018 * * *

"Follow-up radiological surveys were performed and determined that there was no contamination on the worker, response personnel, or ambulance. The Occupation Safety and Health Administration was notified on 11/16/18. No media release is planned."

The NRC Resident Inspector was notified.

Notified the R2DO (Sandal) and via E-mail the NRR EO (Miller) and IRD MOC (Gott).

AGREEMENT STATE REPORT - MISADMINISTRATION OF THERASPHERE MICROSPHERES

The following information was received via E-mail:

"On November 16, 2018, the Agency [Texas Department of State Health Services] was notified by the licensee that a medical event had occurred earlier that day.

"The event occurred when the licensee attempted to treat a patient with 220 grays of Yttrium-90 (TheraSphere) microspheres. After the treatment the injection catheter was removed from the device and placed in a storage container. A survey of the container indicated the dose rate was half of the dose rate prior to injection. The licensee stated they believe only 107.1 Grays of the spheres had been injected into the patient.

"The licensee did not provide the target organ, but will provide it in the written report. The licensee stated the patient would not experience any adverse effects from the event. The licensee stated no individual performing the treatment received any significant exposure. The licensee stated the area was not contaminated. The licensee did not have a cause for the event, but will provide it once determined. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I - 9636

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.

LOSS OF SEALED SOURCE AT VA MEDICAL CENTER

The following is a summary of information provided by the Department of Veterans Affairs via e-mail:

"The source is believed to have been mistakenly discarded with non-radioactive trash on Friday, November 16, 2018. The loss was discovered on Monday November 19, 2018. It is believed that the source is buried deep in a commercial landfill in Johnson City, TN. A radiation survey performed at the landfill did not locate the source.

"The source contains approximately 15 millicuries of cobalt-57.

"The US Department of Veterans Affairs hold NRC Master Materials License No. 03-23853-01VA. The source was lost at the VA Medical Center [located in] Johnson City, TN 37604. This facility holds VA radioactive materials permit number 41-19792-01.

"We expect that doses to personnel from the lost source are and will be much less than the NRC's dose limit for members of the public.

"The State of Tennessee has been notified of the lost source. Also, the VA's NRC Liaison (Parker) of NRC Region III, has also been notified."

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

POSSIBLE MEDICAL OVERDOSE

The following is a summary of a phone call with the licensee's Radiation Safety Officer:

During a NRC inspector audit on October 18, 2022, an apparent overdose was identified when records showed a patient received 21.1 millicuries of I-131 for thyroid therapy. The prescribed dose in the file appeared to read 20 microcuries of I-131 vice 20 millicuries. There were no reported adverse effects for the patient.

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.