Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2019

Event Notification Report for December 24, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/23/2019 - 12/24/2019

** EVENT NUMBERS **

Agreement State	Event Number: 54441
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM Licensee: AUGUSTA UNIVERSITY HEALTH SYSTEM Region: 1 City: AUGUSTA State: GA County: License #: GA 1110-1 Agreement: Y Docket: NRC Notified By: IRENE BENNETT HQ OPS Officer: KARL DIEDERICH	Notification Date: 12/13/2019 Notification Time: 10:17 [ET] Event Date: 12/05/2019 Event Time: 00:00 [EST] Last Update Date: 12/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CHRISTOPHER LALLY (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL MIS-ADMINISTRATION

The following report was received from the Georgia radioactive materials program environmental protection division via email:

"Augusta University Medical Center had an incident yesterday (December 5, 2019) in the Interventional Radiology (IR) Suite during a Y-90 TheraSphere procedure.

"The Y-90 TheraSphere delivery was performed in the usual fashion, per TheraSphere protocol, with 3 flushes of the administration vial. Both delivery and nuclear medicine pre-procedure preparation was performed per standard radiopharmaceutical (TheraSphere) protocol. During administration, the remaining undelivered dose became stuck/trapped in the transport vial and could not be administered.

"About 40 percent of the prescribed radiation dose was delivered to the patient, which is less than the criteria in Rule 391-3-17-.05.(115)a.1(i), which states, 'The total dose delivered differs from the prescribed dose by 20 percent or more.'

"A small amount of the Y-90 microspheres spilled onto the administration table, which was covered with absorbent towels. Augusta University staff isolated the contamination, scanned all IR Suite staff to ensure the contamination was not spread outside the immediate area, and called for assistance with clean-up. All contamination was located and cleaned-up, and all swipes have been counted and the results show no residual contamination in the suite or on any equipment in the suite. All radioactive material has been collected and is being stored and managed as radioactive waste.

"A formal written notification to your office will be submitted within 15 days of the event. This formal written notification will include all of the information required by Rule 391-3-17-.05.(115)."

Georgia Incident No.: 22

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.

Agreement State	Event Number: 54442
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL Licensee: UNIVERSITY OF MIAMI Region: 1 City: MIAMI State: FL County: License #: 1319-1 Agreement: Y Docket: NRC Notified By: MATTHEW SENISON HQ OPS Officer: THOMAS KENDZIA	Notification Date: 12/13/2019 Notification Time: 14:39 [ET] Event Date: 11/22/2019 Event Time: 00:00 [EST] Last Update Date: 12/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CHRISTOPHER LALLY (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - EQUIPMENT FAILURE DURING MEDICAL TREATMENT

The following was received from the Florida Bureau of Radiation Control (the Bureau) via email:

"At [licensee], on or around 1745 EST 22 November 2019, a male patient being treated with Y-90 theraspheres had a blockage on the catheter. The Interventional Radiologist increased the pressure on the line, rupturing the intubation tube. No contamination of staff, only patient. Decontamination of the room and patient followed, no contamination on skin, only gown and tube. Vials were disposed of with waste, so no batch numbers of spheres are available at this time. Problems with imaging occurred, so there are no images at this time. The Radiation Safety Officer (RSO) has asked for reports with more information from Interventional Radiologist (IR) and Radiation Oncologist Authorized User (ROAU). IR and ROAU disagree on how much activity the patient received before the rupture; patient was prescribed 15 mCi. Patient will return for further treatment. The Bureau has been notified and an inspector will be assigned to investigate."

Incident Number: FL19-141

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.

Non-Agreement State	Event Number: 54443
Rep Org: BASF CORPORATION Licensee: BASF CORPORATION Region: 3 City: WYANDOTTE State: MI County: License #: 21-00627-02 Agreement: N Docket: NRC Notified By: DEREK HETES HQ OPS Officer: BETHANY CECERE	Notification Date: 12/13/2019 Notification Time: 14:46 [ET] Event Date: 12/13/2019 Event Time: 00:00 [EST] Last Update Date: 12/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X	Person (Organization): KENNETH RIEMER (R3DO) LAURA PEARSON (ILTAB) NMSS_EVENTS_NOTIFICATION (EMAIL) - CNSC (CANADA) (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

LOST TRITIUM EXIT SIGNS

The following is a synopsis of a telephonic report:

An electrical contractor did not follow disposal instructions and disposed of eight (8) tritium exit signs (approximately 9.5 Ci each) in a dumpster on 12/2/19. The dumpster was removed on 12/4/19. The licensee discovered the error on 12/13/19 when they could locate two of the ten signs planned for removal.

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: 54444
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL Licensee: BOCA RATON REGIONAL HOSPITAL Region: 1 City: BOCA RATON State: FL County: License #: 550-1 Agreement: Y Docket: NRC Notified By: MATTHEW SENISON HQ OPS Officer: THOMAS KENDZIA	Notification Date: 12/13/2019 Notification Time: 14:50 [ET] Event Date: 12/13/2019 Event Time: 00:00 [EST] Last Update Date: 12/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CHRISTOPHER LALLY (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - I-125 SEED MISTAKENLY INCINERATED

The following was received from the Florida Bureau of Radiation Control (the Bureau) via email:

"I-125 therapy seed (243 microCi) was mistakenly incinerated with medical waste. Pathologist mistook metal clip for seed and included it in the material to be incinerated. This information is from a preliminary phone report [to the Bureau]; a full written report with radioactive source info will be submitted via email."

Incident Number: FL19-148

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

Non-Agreement State	Event Number: 54445
Rep Org: WASHINGTON UNIVERSITY IN ST. LOUIS Licensee: WASHINGTON UNIVERSITY IN ST. LOUIS Region: 3 City: ST. LOUIS State: MO County: License #: 24-00167-11 Agreement: N Docket: NRC Notified By: MAXWELL AMURAO HQ OPS Officer: BETHANY CECERE	Notification Date: 12/13/2019 Notification Time: 20:37 [ET] Event Date: 12/13/2019 Event Time: 00:00 [CST] Last Update Date: 12/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE	Person (Organization): KENNETH RIEMER (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

MICROSPHERES DEPOSITED TO DIFFERENT SEGMENT OF LIVER

The following is a synopsis of a telephonic report:

On 12/6/19, a patient was administered Y-90 microspheres, intended for segment 4 of the liver.

On 12/13/19, the post-administration imaging was interpreted and examined. It was determined that, despite taking precautions of blood vessel embolization to limit the microspheres from other segments, some of the microspheres deposited in segment 2 as well as segment 4. The patient was notified. No adverse effects are expected as the microspheres all went to the same lobe of the liver, and within about 95 percent of the prescribed dose.

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 Wednesday, March 24, 2021