Event Notification Report for March 13, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/12/2020 - 03/13/2020
Agreement State
Event Number: 54585
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: THE HOUSTON METHODIST HOSPITAL
Region: 4
City: HOUSTON State: TX
County:
License #: RAM-L00457
Agreement: Y
Docket:
NRC Notified By: RANDALL REDD
HQ OPS Officer: JEFFREY WHITED
Licensee: THE HOUSTON METHODIST HOSPITAL
Region: 4
City: HOUSTON State: TX
County:
License #: RAM-L00457
Agreement: Y
Docket:
NRC Notified By: RANDALL REDD
HQ OPS Officer: JEFFREY WHITED
Notification Date: 03/13/2020
Notification Time: 19:28 [ET]
Event Date: 03/13/2020
Event Time: 00:00 [CDT]
Last Update Date: 03/13/2020
Notification Time: 19:28 [ET]
Event Date: 03/13/2020
Event Time: 00:00 [CDT]
Last Update Date: 03/13/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following was received from the State of Texas via email:
"On March 13, 2020, [the Texas Department of State Health Services] was notified by the Houston Methodist Hospital of a medical event. The patient was to receive 18.4 Gy of therapeutic dose from a Novoste Beta-Cath system Sr-90 source (system serial no. 89670, source train serial no. za925). When the procedure began, the command was sent to the system to deliver the source. The source did not appear within the fluoro field as expected after 10 seconds and the command was sent to the system to retract the source. The source failed to retract. The oncologist manually removed the catheter from the patient and found the source stuck inside. It is now back in the system. The licensee has been reminded that they need to notify the referring physician within 24 hours. An investigation into this event is ongoing. More information will be provided when obtained in accordance with SA-300."
Texas Incident Number: 9751
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 from the State of Texas via email:
"On March 13, 2020, [the Texas Department of State Health Services] was notified by the Houston Methodist Hospital of a medical event. The patient was to receive 18.4 Gy of therapeutic dose from a Novoste Beta-Cath system Sr-90 source (system serial no. 89670, source train serial no. za925). When the procedure began, the command was sent to the system to deliver the source. The source did not appear within the fluoro field as expected after 10 seconds and the command was sent to the system to retract the source. The source failed to retract. The oncologist manually removed the catheter from the patient and found the source stuck inside. It is now back in the system. The licensee has been reminded that they need to notify the referring physician within 24 hours. An investigation into this event is ongoing. More information will be provided when obtained in accordance with SA-300."
Texas Incident Number: 9751
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: 54608
Rep Org: PA DEPT OF ENVIRONMENTAL PROTECTION
Licensee: ISOLITE CORPORATION
Region: 1
City: BERWYN State: PA
County:
License #: PA-1371A
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: KERBY SCALES
Licensee: ISOLITE CORPORATION
Region: 1
City: BERWYN State: PA
County:
License #: PA-1371A
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: KERBY SCALES
Notification Date: 03/25/2020
Notification Time: 11:58 [ET]
Event Date: 03/13/2020
Event Time: 00:00 [EDT]
Last Update Date: 03/25/2020
Notification Time: 11:58 [ET]
Event Date: 03/13/2020
Event Time: 00:00 [EDT]
Last Update Date: 03/25/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS
The following was received from the Commonwealth of Pennsylvania via email:
"The [Pennsylvania] Department [of Environmental Protection] received notification from a licensee on March 23, 2020 of the loss or theft of four tritium exit signs during shipment from the manufacturer/distributor in Canada to distributer/installer in [Winter Haven,] Florida. The tritium exit signs are model number 880-20-1-BK-BA-MB, 12.57 Curies each for a total of 50.28 Curies. The serial numbers are: H135434, H135435, H135436, H135437. The shipper believes the package was delivered on December 5, 2019, but the Florida installer didn't determine the material to be lost until March 13, 2020. An investigation with [the common carrier] has already begun to find the package. The [Department] will update this event as soon as more information is provided.
"The Department will perform a reactive inspection as soon as possible."
PA Event Report ID No: PA200006
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 was received from the Commonwealth of Pennsylvania via email:
"The [Pennsylvania] Department [of Environmental Protection] received notification from a licensee on March 23, 2020 of the loss or theft of four tritium exit signs during shipment from the manufacturer/distributor in Canada to distributer/installer in [Winter Haven,] Florida. The tritium exit signs are model number 880-20-1-BK-BA-MB, 12.57 Curies each for a total of 50.28 Curies. The serial numbers are: H135434, H135435, H135436, H135437. The shipper believes the package was delivered on December 5, 2019, but the Florida installer didn't determine the material to be lost until March 13, 2020. An investigation with [the common carrier] has already begun to find the package. The [Department] will update this event as soon as more information is provided.
"The Department will perform a reactive inspection as soon as possible."
PA Event Report ID No: PA200006
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