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Event Notification Report for March 31, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
3/30/2020 - 3/31/2020

** EVENT NUMBERS **

Agreement State	Event Number: 54591
Rep Org: COLORADO DEPT OF HEALTH Licensee: KARCHER NORTH AMERICA Region: 4 City: ENGLEWOOD State: CO County: License #: GL001195 Agreement: Y Docket: NRC Notified By: KATHRYN MOTE HQ OPS Officer: THOMAS KENDZIA	Notification Date: 03/20/2020 Notification Time: 10:00 [ET] Event Date: 11/26/2018 Event Time: 00:00 [MDT] Last Update Date: 03/20/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): NEIL O'KEEFE (R4DO) 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 STATIC ELIMINATOR

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

On November 11, 2018, Karcher North America reported that one static eliminator was lost. The device contained 0.01 Ci of radioactive material. The radioactive material was not identified. Research identified that alpha emitters, such as poloniun-210, were normally used in static eliminators.

* * * UPDATE ON 03/20/2020 AT 1259 EDT FROM KATHRYN MOTE TO OSSY FONT * * *

The following update was received from the state of Colorado via email:

The State notified the NRC that the lost radioactive material was polonium-210.

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: 54592
Rep Org: COLORADO DEPT OF HEALTH Licensee: INVERNESS HOTEL AND CONFERENCE CTR Region: 4 City: ENGLEWOOD State: CO County: License #: GL001275 Agreement: Y Docket: NRC Notified By: KATHRYN MOTE HQ OPS Officer: OSSY FONT	Notification Date: 03/20/2020 Notification Time: 13:57 [ET] Event Date: 12/29/2017 Event Time: 00:00 [MDT] Last Update Date: 03/20/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): NEIL O'KEEFE (R4DO) 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 TRITIUM EXIT SIGN

The following is a summary of information received from the state of Colorado via email:

A 5.75 Ci tritium exit sign was confirmed lost through annual registration.

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: 54593
Rep Org: COLORADO DEPT OF HEALTH Licensee: HOTEL MONACO Region: 4 City: DENVER State: CO County: License #: GL001905 Agreement: Y Docket: NRC Notified By: KATHRYN MOTE HQ OPS Officer: OSSY FONT	Notification Date: 03/20/2020 Notification Time: 16:09 [ET] Event Date: 06/10/2019 Event Time: 00:00 [MDT] Last Update Date: 03/20/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): NEIL O'KEEFE (R4DO) 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 TRITIUM EXIT SIGNS

The following is a summary of information received from the state of Colorado via email:

The State is reporting 71 lost tritium exit signs, each containing 7.09 Ci. They were confirmed lost through annual registration. The signs were likely lost during renovations.

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: 54595
Rep Org: WISCONSIN RADIATION PROTECTION Licensee: AURORA BAYCARE MEDICAL CENTER Region: 3 City: GREEN BAY State: WI County: License #: 009-1017-01 Agreement: Y Docket: NRC Notified By: MEGAN SHOBER HQ OPS Officer: OSSY FONT	Notification Date: 03/20/2020 Notification Time: 18:30 [ET] Event Date: 03/20/2020 Event Time: 00:00 [CDT] Last Update Date: 03/25/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JOHN HANNA (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNPLANNED DOSE TO AN ORGAN

The following was received from the state of Wisconsin's Radiation Protection Section [the Department] via email:

"On March 20, 2020, the [Wisconsin Radiation Protection Section] Department was notified by the licensee of a medical event which occurred the same day. The licensee was performing the first fraction of a vaginal cylinder treatment using a Varian VariSource iX high dose rate remote afterloader unit. Licensee staff had difficulty removing the cylinder post-treatment, and they determined that the cylinder had perforated the patient's tissue at some point following pre-treatment imaging. The licensee estimates the cylinder moved 3-4 cm from its original position. Dose reconstruction is ongoing, but is expected to exceed the 0.5 Sv threshold to the bowel. This is all the information available at this time. The Department will determine follow-up actions and provide additional information when available."

* * * UPDATE ON 3/25/20 AT 1612 EDT FROM MEGAN SHOBER TO BETHANY CECERE * * *

"The Department performed an investigation on March 25, 2020 to review this incident. For this fraction, the patient was prescribed a 6 Gy dose to the surface of the vaginal cylinder. Using CT imaging the licensee confirmed the proper placement of the cylinder prior to treatment. The licensee performed all pre-treatment checks, connected the patient to the HDR unit, and initiated treatment. Everything appeared to be as expected. However, following treatment it was very difficult for the authorized user to remove the cylinder; there appeared to be a vacuum suction seal. The licensee determined that the cylinder had been pulled an additional 3.5 cm into the patient, perforating the vaginal wall and protruding into the bowel space. The licensee believes that the bowel conformed to the shape of the cylinder during part or all of treatment, causing a much larger volume of the bowel to receive an elevated radiation dose as compared to the treatment plan. Based on the prescribed dose, the maximum unintended dose to the bowel is 6 Gy. The patient and referring physician were immediately informed of the event. The authorized user does not expect the patient to experience any radiological consequences from this event."

Wisconsin Event Report ID No.: WI200010

Notified R3DO (Hanna) and NMSS Events Notification Email.

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: 54598
Rep Org: COLORADO DEPT OF HEALTH Licensee: THE VIEWHOUSE Region: 4 City: DENVER State: CO County: License #: GL002342 Agreement: Y Docket: NRC Notified By: KATHRYN MOTE HQ OPS Officer: JEFFREY WHITED	Notification Date: 03/23/2020 Notification Time: 11:30 [ET] Event Date: 06/13/2019 Event Time: 00:00 [MDT] Last Update Date: 03/23/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RAY KELLAR (R4DO) 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 TRITIUM EXIT SIGNS

The following is a summary of information received from the state of Colorado via email:

Two tritium exit signs (6.5 Ci each) were not found during a walk down of the facility. Management claims they were not received or installed.

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: 54600
Rep Org: COLORADO DEPT OF HEALTH Licensee: WARWICK HOTEL Region: 4 City: DENVER State: CO County: License #: GL000858 Agreement: Y Docket: NRC Notified By: KATHRYN MOTE HQ OPS Officer: OSSY FONT	Notification Date: 03/23/2020 Notification Time: 14:53 [ET] Event Date: 12/20/2017 Event Time: 00:00 [MDT] Last Update Date: 03/23/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RAY KELLAR (R4DO) 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 TRITIUM EXIT SIGNS

The following summary was received from the state of Colorado via email:

Four tritium exit signs, containing 7.5 Ci each, were determined lost, disposed of before the current manager took the management position.

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: 54601
Rep Org: RI DEPT OF RADIOLOGICAL HEALTH Licensee: RHODE ISLAND HOSPITAL Region: 1 City: PROVIDENCE State: RI County: License #: 7A-051-02 Agreement: Y Docket: NRC Notified By: MARIA BARNES HQ OPS Officer: OSSY FONT	Notification Date: 03/23/2020 Notification Time: 16:58 [ET] Event Date: 03/03/2020 Event Time: 00:00 [EDT] Last Update Date: 03/23/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CHRISTOPHER CAHILL (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL) MICHAEL LAYTON (DD) KEVIN WILLIAMS (EMAIL) PATRICIA MILLIGAN (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION (ABNORMAL OCCURRENCE)

The following was received from the Rhode Island Department of Health (RIDOH; the Department) via email:

"On March 4, 2020, the Department's staff at RIDOH, Radiation Control Program became aware of a medical event (ME) that occurred at the Rhode Island Hospital, Department of Radiation Oncology in Providence on March 3, 2020. The ME is reportable as per 10 CFR 35.3045(a)(1)(i)(A) and meets the criteria for an Abnormal Occurrence.

"On March 3, 2020, a patient underwent Gamma Knife treatment of a left vestibular schwannoma. At the conclusion of the treatment it was discovered that the location of the anterior screws securing the patient's head in the treatment position had moved. Before the patient was moved from the treatment table, the patient's position was observed by the radiation oncologist, neurosurgeon, and medical physicist. It is unknown at this time what contributed to the event and how the screws securing the patient in the treatment position had shifted from the initial position. Based on information provided by the patient and other participants associated with this event, a delivered dose was estimated using the GammaPlan Treatment Planning System. The estimated delivery to the target coverage area (volume of tissue receiving dose) was 44 percent. The estimated dose to the target was 4 Gy (400 rad). An unintended dose to a region of the left temporal lobe within the brain was estimated to be 13.6 Gy (1,360 rad). On the day of the incident, the attending neurosurgeon spoke directly with the patient informing the patient that the stereotactic frame had disengaged from his head at some point midway through the treatment and resulted in an unclear radiation dose to the tumor. The patient was informed of the estimated dose and told of the licensee's plan to obtain a follow-up brain MRI within 1-2 weeks after treatment and approximately 3 months after treatment."

The licensee is taking a number of corrective actions, including having the radiation therapist ensure that the patient understands that any movement of their head within the headframe is not anticipated and should be communicated immediately.

Event Report ID No: RI2020-01

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