Event Notification Report for March 07, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/06/2019 - 03/07/2019
Non-Agreement State
Event Number: 53914
Rep Org: ELI LILLY AND COMPANY
Licensee: ELI LILLY AND COMPANY
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-01133-02
Agreement: N
Docket:
NRC Notified By: TRENTON MAYS
HQ OPS Officer: ANDREW WAUGH
Licensee: ELI LILLY AND COMPANY
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-01133-02
Agreement: N
Docket:
NRC Notified By: TRENTON MAYS
HQ OPS Officer: ANDREW WAUGH
Notification Date: 03/07/2019
Notification Time: 12:30 [ET]
Event Date: 03/07/2019
Event Time: 00:00 [EST]
Last Update Date: 03/07/2019
Notification Time: 12:30 [ET]
Event Date: 03/07/2019
Event Time: 00:00 [EST]
Last Update Date: 03/07/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
LOST TRITIUM EXIT SIGN
The following is a summary of a phone call with the licensee:
During a routine inventory Eli Lilly and Company discovered that one of their tritium exit signs was missing. The company believes the sign went missing during a remodeling project. The company is still actively looking for the sign, but believes that it is out of their possession at this time.
The tritium exit sign, serial number A11223, was manufactured by Isolite in January of 2001. The activity at the time of manufacturing was 7.5 Ci, which would be approximately 2.5 Ci today.
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 is a summary of a phone call with the licensee:
During a routine inventory Eli Lilly and Company discovered that one of their tritium exit signs was missing. The company believes the sign went missing during a remodeling project. The company is still actively looking for the sign, but believes that it is out of their possession at this time.
The tritium exit sign, serial number A11223, was manufactured by Isolite in January of 2001. The activity at the time of manufacturing was 7.5 Ci, which would be approximately 2.5 Ci today.
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
Agreement State
Event Number: 53932
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TEXAS ONCOLOGY PA
Region: 4
City: AUSTIN State: TX
County:
License #: L05108
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOANNA BRIDGE
Licensee: TEXAS ONCOLOGY PA
Region: 4
City: AUSTIN State: TX
County:
License #: L05108
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 03/14/2019
Notification Time: 16:05 [ET]
Event Date: 03/07/2019
Event Time: 00:00 [CDT]
Last Update Date: 03/14/2019
Notification Time: 16:05 [ET]
Event Date: 03/07/2019
Event Time: 00:00 [CDT]
Last Update Date: 03/14/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MISADMINISTRATION OF DOSE TO PATIENT
The following was received via e-mail:
"On March 14, 2019, the Texas Department of Health Services was notified by the licensee's radiation safety officer (RSO) that a therapy event had occurred. A patient was scheduled for three fractions using a high dose rate after loader containing a 6.8 curie iridium-192 source. Multiple catheters were to be used. On March 14, 2019, prior to the third fraction, the licensee determined that one of the catheters was shorter than the length required and the patient received 350 centigrays (50 percent) of the prescribed dose to the thigh resulting in the target tissue receiving 50 percent of the prescribed dose (350 centigrays). The third fraction was not administered. The RSO stated they intended to create a new treatment plan to correct the error and insure the intended area receives the correct dose. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: 9665
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.
The following was received via e-mail:
"On March 14, 2019, the Texas Department of Health Services was notified by the licensee's radiation safety officer (RSO) that a therapy event had occurred. A patient was scheduled for three fractions using a high dose rate after loader containing a 6.8 curie iridium-192 source. Multiple catheters were to be used. On March 14, 2019, prior to the third fraction, the licensee determined that one of the catheters was shorter than the length required and the patient received 350 centigrays (50 percent) of the prescribed dose to the thigh resulting in the target tissue receiving 50 percent of the prescribed dose (350 centigrays). The third fraction was not administered. The RSO stated they intended to create a new treatment plan to correct the error and insure the intended area receives the correct dose. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: 9665
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.