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Event Notification Report for April 09, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/8/2019 - 4/9/2019

** EVENT NUMBERS **


53963 53964 53965

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Agreement State Event Number: 53963
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: NOVANT HEALTH PRESBYTERIAN MEDICAL CENTER
Region: 1
City: CHARLOTTE   State: NC
County:
License #: 060-0019-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JEFF HERRERA
Notification Date: 03/29/2019
Notification Time: 11:01 [ET]
Event Date: 03/05/2019
Event Time: 00:00 [EDT]
Last Update Date: 03/29/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - INCORRECT SOURCE STRENGTH ENTERED RESULTING IN OVERDOSE OF 20 PERCENT

The following report was received from the North Carolina Division of Health Service Regulation via email:

"A prostate patient returned for a 30 day post treatment review and CT scan. Licensee Physics Group reviewed the Post Op Plan with the Intended Plan. It was found that when the Intended Plan was entered into the planning software, a dosimetrist entered an incorrect source strength into the planning system, causing the planning system to appear to be implanting weaker seeds than were being implanted resulting in an over dose of 20 percent.

"Event Date: 3/5/19
Discovered Date: 3/28/1
Prescribed dose: 164.85 mCi
Administered dose: 213.15 mCi
Isotope: PD-103.
Target organ: Prostate
Referring Physician notified on: 3/28/19
Patient notified on: 3/28/19
Effects/Outcome to the Patient: None anticipated. Physician will monitor patient for side effects.
Notifications & Generic Implications: None.
Corrective Action: Procedure revision.

"A reactive inspection was conducted today [by the North Carolina Division of Health Service Regulation]. Following this entry into NMED we [the North Carolina Division of Health Service Regulation] would like to request the event be closed and complete. We [the North Carolina Division of Health Service Regulation] have concluded our investigation.

"NC Tracking Number: 190011"

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: 53964
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: MESKEL & ASSOCIATES ENGINEERING, PLLC
Region: 1
City: JACKSONVILLE   State: FL
County: DUVAL
License #: 4344-1
Agreement: Y
Docket:
NRC Notified By: MATTHEW G SENISON
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 03/29/2019
Notification Time: 15:44 [ET]
Event Date: 03/29/2019
Event Time: 11:00 [EDT]
Last Update Date: 03/29/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST TROXLER DENSITY GAUGE

"At around 1:50 p.m. EDT, [the radiation safety officer] of Meskel Associates called to notify the BRC [Bureau of Radiation Control] of the loss of a Troxler Soil Moisture Density Gauge Model 3440 S/N 17405, source numbers 507-6784 & 47-12827. The gauge fell off of the back of a pickup truck because the tailgate was down and the gauge was not secured. No injuries were reported, the licensee checked with FHP for collision reports. Five people from the licensee looked for it, none found it."

Florida Incident Number FL19-046

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: 53965
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: ADVENTIST HEALTH SYSTEM
Region: 1
City: DAYTONA   State: FL
County:
License #: 2897-1
Agreement: Y
Docket:
NRC Notified By: TIM DUNN
HQ OPS Officer: ANDREW WAUGH
Notification Date: 03/29/2019
Notification Time: 16:23 [ET]
Event Date: 03/29/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/06/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOSS OF AN I-125 SEED

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

"Received a call from Adventist Health to report the loss of an I-129 seed that was removed from a patient. According to [Adventist Health], the seed was removed on 2/19/2019 and discovered missing on 2/20/2019, all attempts to locate the seed have been unsuccessful. It is believed that the seed was discarded with the medical waste and sent to the incinerator. A preliminary report will be sent to [the Florida Bureau of Radiation Control] as soon as possible, and followed up with the official report from the hospital when their investigation is complete."

Florida Incident Number: FL19-047

* * * UPDATE ON 4/5/2019 AT 1602 EDT FROM TIM DUNN TO MARK ABRAMOVITZ * * *

The following report was received via e-mail:

"Adventist Health reported the loss of an I-125 seed that was removed from a patient. The seed was removed [from the patient] on Feb. 19th and discovered missing on Feb. 20th, all attempts to locate the seed have been unsuccessful. It is believed that the seed was discarded with the medical waste and sent to the incinerator.

"There was no adverse outcome in patient care from this incident. The seed was either disposed of in biohazard or normal trash. In either case, the portal monitors would not have measured the radiation emitted from the seed due to the low activity. No personnel or general public exposure would have been significant based upon the low exposure rate and the nature of controlled biohazard waste. The waste was incinerated. No environmental impact is expected.

"Corrective actions taken as a result of the loss of this source:
1) Surgery will survey the specimen when placed in the bag before sending to imaging. Education on this process has occurred to ensure compliance.
2) X-ray will scan the specimen placed in the bag with a survey meter when obtaining the specimen x-ray, prior to going to pathology. Education on this process has occurred to ensure compliance.
3) Pathology will survey the specimen upon receipt to confirm the seed is present. Reeducation on this process has occurred to ensure compliance."

This event was previously reported as a loss of an I-129 seed, which was incorrect.

Seed activity: 241 microCuries

Notified R1DO (Young) and NMSS Events and ILTAB (via e-mail).


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


Page Last Reviewed/Updated Thursday, July 11, 2019
Thursday, July 11, 2019