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Event Notification Report for November 29, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/28/2019 - 11/29/2019

** EVENT NUMBERS **


54395 54396 54397 54398 54399 54400 54402

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Agreement State Event Number: 54395
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: VANDERBILT UNIVERSITY
Region: 1
City: NASHVILLE   State: TN
County:
License #: R-19266
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/20/2019
Notification Time: 09:28 [ET]
Event Date: 11/14/2019
Event Time: 00:00 [EST]
Last Update Date: 11/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
SOPHIE HOLIDAY (NMSS DAY)

Event Text

TENNESSEE AGREEMENT STATE REPORT - MEDICAL EVENT THAT RESULTED IN SKIN INJURY

The following information was received from the state of Tennessee via email:

"Patient treated with Lutathera (Lu-177 dotatate) on November 14, 2019. It was determined during her infusion that the Foley catheter was leaking. After the leak was identified, proper decontamination procedures were performed. The patient was instructed upon discharge that there was a chance for potential skin injury. Licensee reported that the estimated skin dose was 7 Gray (Gy). On November 18, 2019, the patient informed her provider that there was skin irritation in the peri-gluteal and peri-labia areas. It was determined that this was skin injury consistent with radiation injury. A follow-up report will be submitted upon receipt of a written report from the licensee."

Tennessee Event Report ID No.: TN-19-161

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: 54396
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SUN VALLEY PAPER STOCK, INC
Region: 4
City: SUN VALLEY   State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 11/20/2019
Notification Time: 14:04 [ET]
Event Date: 11/15/2019
Event Time: 11:18 [PST]
Last Update Date: 11/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - RADIOACTIVE MATERIAL FOUND IN WASTE TRANSFER TRUCK

The following report was received from the State of California via email:

"[The] Division Manager from Burrtec Waste Industries, Inc., reported on November 15, 2019 that his route truck activated the radiation alarm at Sun Valley Paper Stock, Inc.

"Truck No. 1087, License Plate No. 7Y45540 driven by [a] Burrtec employee arrived at the transfer station at about 1130 PST on the same day. [A California Department of Public Health (CDPH), Health Physicist] arrived at the transfer station around 1430 PST and met with [the] Plant Manager. Using the FLIR Identifinder 2, the nuclide was identified as Ra-226. [The CDPH Health Physicist] contacted [the] Director of Radiation Management about the incident and the nuclide that was identified. Before [the CDPH Health Physicist] left he made arrangements with [the Plant Manager] that he will be back on Tuesday November 19, 2019 to dump the entire contents of the transfer truck to locate the radiation source and take custody of it.

"On November 19, 2019, [a CDPH and a Los Angeles County Public Health (LACPH), Health Physicist] arrived at the transfer station at 1000 PST. The entire contents of the truck was dumped, and surveyed. Using the FLIR Identifinder 2 [the Health Physicists] were able to locate the radioactive source containing Ra-226. The radioactive source was a piece of metallic object. It was placed in a gallon size ziploc bag. Using a Ludlum 26-3, no contamination was noted. Using a Victoreen 451, background was 5 microR/hr, the gross exposure rate from surface was 54mR/hr, 4.8mR/hr at 1 ft, and 0.48mR/hr at 3 ft and calculated activity of 544 microCuries. The rest of the trash was surveyed and no other sources were noted. An authorization to bury form was emailed to [the Plant Manager] on the same day for the rest of the load. [The] LACPH Health Physicist took possession of the metal item and transported it to a secure location facility."

California incident No.: 111519

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Agreement State Event Number: 54397
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: UNIVERSITY OF VIRGINIA
Region: 1
City: CHARLOTTESVILLE   State: VA
County:
License #: 540-248-1
Agreement: Y
Docket:
NRC Notified By: ASFAW FENTA
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/20/2019
Notification Time: 16:39 [ET]
Event Date: 11/19/2019
Event Time: 00:00 [EST]
Last Update Date: 11/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DOSE LESS THAN PRESCRIBED DELIVERED TO TREATMENT SITE

The following information was received via E-mail:

"On November 20, 2019, the licensee notified the Virginia Office of Radiological Health (ORH) that a medical event occurred as a result of treating a patient using a High Dose Remote Afterloader Unit (HDR). According to the written directive, 18 Gray (Gy) dose to the neck, in three (3) fractions of 6 Gy, was prescribed. On November 19, 2019, the first of the three fractions was delivered. However, the dose was delivered at 91.5 cm instead of the intended 118.1 cm. This resulted in a dose to the treatment site of approximately 0.3 Gy.

"The report indicated that the error was discovered on November 20, 2019 at 0830 EST after the medical physicist re-measured the guide tube and catheter. It was discovered that the guide tube and catheter were not connected properly and this caused the dose to be delivered at 91.5 cm.

"The prescribing physician and the patient were notified immediately (at 0915 EST).

"ORH will review the licensee's written report and determine additional actions to be taken."

Virginia Event Report ID No.: VA-19-005

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: 54398
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT PROVIDED
Region: 1
City:   State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DANIEL SAMSON
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 11/20/2019
Notification Time: 16:52 [ET]
Event Date: 11/20/2019
Event Time: 13:00 [EST]
Last Update Date: 11/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - IODINE 125 SEED MIGRATED FROM IMPLANT LOCATION

The following was received from the State of New York via fax:

"The New York State Department of Health (NYSDOH) was notified by a NYS medical licensee that they had an incident where an lodine-125 seed (200 microCi assayed on 11/12/2019) had migrated from the original implant location in the left breast of a female patient.

"According to the licensee, two seeds were implanted on 11/18/2019 for localization during an 11/20/2019 procedure. During this procedure on 11/20/2019, it was noticed by the surgeon that one of the seeds had migrated about 2 inches from its original implant location. The surgeon and radiologist concluded that any attempt to retrieve the seed in question would compromise patient care. The seed was not retrieved as a result.

"The facility contacted the New York State Department of Health two hours after the licensee determined that the lodine-125 localization seed could not be retrieved from the patient and will be submitting a written report within the required timeframe.

"DOH will continue to monitor this incident."

New York State incident No.: 19-07

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: 54399
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: BLACKWELL HOSPITAL TRUST AUTHORITY
Region: 4
City: BLACKWELL   State: OK
County:
License #: 32140-01
Agreement: Y
Docket:
NRC Notified By: LIBBY MCCASKILL
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 11/20/2019
Notification Time: 17:04 [ET]
Event Date: 11/06/2019
Event Time: 00:00 [CST]
Last Update Date: 11/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MISADMINISTRATION OF RADIONUCLIDE

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

"[The Oklahoma Department of Environmental Quality (ODEQ)] was notified by phone today that on November 6, Oklahoma licensee Blackwell Hospital Trust Authority (OK-32140-01) had administered a dose of Tc-99m Sestamibi to a patient that [the dose] was 24-hours old. The RSO reported that she had learned of the incident today and that the dose was administered to the intended patient. The activity of the dose originally is unknown at this time.

"The licensee will be investigating the event further to determine the details of what happened.

"[The ODEQ] will update this notice with more information as [the ODEQ] receives it."

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: 54400
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: EARTH SOLUTIONS NORTHWEST
Region: 4
City: EDMONDS   State: WA
County:
License #: WN-I0560-1
Agreement: Y
Docket:
NRC Notified By: ANDREW HALLORAN
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 11/20/2019
Notification Time: 17:10 [ET]
Event Date: 11/20/2019
Event Time: 10:00 [PST]
Last Update Date: 11/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DENSITY GAUGE DAMAGED

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

"A portable gauge (CPN MC-1 DRP, S/N MD10306057, last leak test 7/18/2019) was run over by a skid-steer at a temporary job site. The gauge operator stated that he was performing measurements and set the gauge down when the skid-steer operator did not fully check his surroundings and backed over the gauge. The gauge operator immediately had everyone move to the edge of the site and they are holding there until the gauge is removed from the site and it is verified that the sources were not compromised. [WA State Department of Health] personnel arrived to the location and assisted in performing surveys to verify whether the sealed sources had been compromised. Field screening of wipes found no removable contamination, and the source rod was able to be retracted. An inspector will perform an investigation with the licensee during the routine inspection scheduled for 11/21/2019. More information to follow in an update."

Washington Incident No.: 19-032

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Agreement State Event Number: 54402
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: PROFESSIONAL SERVICE INDUSTRIES
Region: 4
City: Cave City   State: AR
County:
License #: ARK-0943-03121
Agreement: Y
Docket:
NRC Notified By: CHRIS TALLEY
HQ OPS Officer: BRIAN P. SMITH
Notification Date: 11/21/2019
Notification Time: 14:53 [ET]
Event Date: 11/19/2019
Event Time: 16:00 [CST]
Last Update Date: 11/21/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DENSITY GAUGE DAMAGED

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

"The [Arkansas] Department [of Health] received notification on November 20, 2019, from licensee Professional Services Industries, Inc., that a Troxler gauge model 3430 had been struck by a skid-steer while performing routine measurements at a road construction site. The gauge was not being used at the time it was struck and the sources were in the shielded position.

"Upon review of the event, it was noted that the technician quickly created a thirty foot containment barrier and notified his company's Radiation Safety Officer (RSO). The RSO for Professional Services Industries mobilized to the event location.

"Once onsite, the RSO surveyed the immediate area around the damaged gauge and the gauge itself. The RSO determined that no radiation measurements were found to be above normal levels for that model of portable gauge. A leak test of the sealed sources was immediately conducted and the remnants of the gauge were collected and returned to the permanent storage location on November 19, 2019. The RSO and the Authorized User operating the portable gauge were wearing dosimetry.

"The Arkansas Department of Health considers this investigation open pending receipt and review of the licensee's 30 day report."

Arkansas Event No.: AR-2019-005


Page Last Reviewed/Updated Friday, November 29, 2019
Friday, November 29, 2019