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Event Notification Report for February 24, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/21/2020 - 2/24/2020

** EVENT NUMBERS **


54526 54527

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Agreement State Event Number: 54526
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: MASSACHUSETTS GENERAL HOSPITAL
Region: 1
City: Boston   State: MA
County:
License #: 60-0055
Agreement: Y
Docket:
NRC Notified By: KENATH TRAEGDE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/14/2020
Notification Time: 16:01 [ET]
Event Date: 02/13/2020
Event Time: 13:45 [EST]
Last Update Date: 02/14/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE OF YTTRIUM-90 DURING TREATMENT

"A medical event was reported to the Massachusetts Radiation Control Program on Friday, February 14, 2020. A patient receiving a therapeutic radiation dose to the right lobe of the liver using Y-90 Theraspheres in 2 fractionated doses was intended to receive 135 Grays for each fraction. The patient was administered 45.5 Grays for the first fraction and 129.4 Grays for the second. The first fraction underdosed the right lobe of the liver by greater than 50 percent and differed from the prescribed dose by greater than 0.5 Sv (50 rem) effective dose equivalent. The actual underdose for the first fraction was 8,950 rads. This exceeds the reporting limits of 10 CFR 35.3045(a)(1)(i)(c), 'Report and Notification of a Medical Event,' and 105 CMR 120.594(A)(1)(a)(3).

"The licensee is investigating the cause of the event and will be reporting the results to the Massachusetts Radiation Control Program. "

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Agreement State Event Number: 54527
Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: MB-MICROTECH USA INC.
Region: 1
City: DEERFIELD BEACH   State: FL
County:
License #: ME 05331
Agreement: Y
Docket:
NRC Notified By: CATHERINE PERHAM
HQ OPS Officer: BRIAN LIN
Notification Date: 02/14/2020
Notification Time: 16:37 [ET]
Event Date: 02/14/2020
Event Time: 14:44 [EST]
Last Update Date: 02/14/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MISSING TRITIUM WATCHES

The following is a synopsis of an email received from the Maine Radiation Control Program:

Fifty-two [self-luminous] watches containing 100 milliCuries each of Tritium were reported as missing or stolen from a shipment delivered to OKO International of Deerfield Beach, Florida. The watches were in transit from Hong Kong to Windsor, Maine. They were part of a shipment of 32 boxes containing a total of 2365 watches. Seven boxes were torn during transport and were re-packaged into five boxes. Upon arrival in Florida, there were 52 watches missing. The brand of watch is reported as an Aragon, with no model or serial number provided yet. Transport was via a common carrier. The licensee reported the theft to the Maine Radiation Control Department at 1444 [EST] on Friday, February 14, 2020. An open investigation is still ongoing with the state of Maine.

Maine Incident No.: ME 20-001


Page Last Reviewed/Updated Monday, February 24, 2020
Monday, February 24, 2020