Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2020

Event Notification Report for April 30, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/29/2020 - 4/30/2020

** EVENT NUMBERS **

Agreement State	Event Number: 53996
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM Licensee: PIEDMONT HOSPITAL Region: 1 City: ATLANTA State: GA County: License #: GA 292-1 Agreement: Y Docket: NRC Notified By: IRENE BENNETT HQ OPS Officer: CATY NOLAN	Notification Date: 04/12/2019 Notification Time: 13:21 [ET] Event Date: 04/03/2019 Event Time: 00:00 [EDT] Last Update Date: 04/29/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): ANNE DeFRANCISCO (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

EN Revision Imported Date : 4/30/2020

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE ADMINISTRATION OF Y-90 THERASPHERES

The following is a synopsis of the information received from the Radioactive Materials Program of Georgia received via email:

On April 3, 2019, an underdose of Y-90 TheraSpheres was administered to a patient. Only 65% of the prescribed dose was administered. On April 5, 2019, the remainder of the prescribed dose was delivered to the patient.

There is no definitive cause identified at this time but the licensee has concluded that it was probably a delivery equipment problem (perhaps with the tubing).

The licensee will follow-up with a formal report.

* * * UPDATE FROM IRENE BENNETT TO HOWIE CROUCH (VIA EMAIL) ON 4/29/20 AT 1553 EDT * * *

The state of Georgia amended the original report to state that the deliver apparatus is awaiting decay to background and will be examined locally or will be sent to the manufacturer for a root cause analysis.

The prescribed dose was 127 Gy. The delivered dose was 59.8 Gy which is 47% of prescribed dose. As stated above, the patient was informed and returned two days later to complete the treatment.

NMED Item: 190182

Notified R1DO (Schroeder) 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: 54676
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL Licensee: INTERNATIONAL PAPER Region: 1 City: MAYSVILLE State: KY County: License #: 401-531-410 Agreement: Y Docket: NRC Notified By: RUSSELL HESTAND HQ OPS Officer: OSSY FONT	Notification Date: 04/22/2020 Notification Time: 14:23 [ET] Event Date: 04/22/2020 Event Time: 10:42 [CDT] Last Update Date: 04/22/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): FRANK ARNER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - GAUGE SYSTEM SWITCH FAILURE

The following was received from the state of Kentucky via fax:

"Kentucky Radiation Health Branch was notified on 4/22/20 by a representative from International Paper of a failure of a magnetic reed switch on their Honeywell gauging system. This switch senses when the mass measurement heads are separated and closes the shutter window on the radioactive source. There are two other means of determining whether the heads are out-of-alignment that also trigger the shutter window to close if indicated. Therefore, these additional layers of protection are adequate to protect against a radiation exposure if the heads are separated. International Paper has returned the system to service with the Honeywell recommendation to replace the switch as soon as the replacement part arrives. Per [the representative] of Honeywell, with the understanding that the failed component will be replaced, the customer can continue to keep the scanner under operation with the basis weight sensor."

Page Last Reviewed/Updated Thursday, March 25, 2021