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Event Notification Report for July 28, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/27/2020 - 7/28/2020

** EVENT NUMBERS **


54786 54787 54788 54790 54791 54793

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Agreement State Event Number: 54786
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UF Health Jacksonville, Shands
Region: 1
City: Jacksonville   State: FL
County:
License #: 3157-1
Agreement: Y
Docket:
NRC Notified By: John A. Williamson
HQ OPS Officer: Ossy Font
Notification Date: 07/17/2020
Notification Time: 09:49 [ET]
Event Date: 07/16/2020
Event Time: 00:00 [EDT]
Last Update Date: 07/17/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

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

"On July 16, 2020, a 54 year old man was mistakenly provided two doses of Tc-99 Sestamibi for heart stress test. Two doses were administered with a total activity of 41.6 mCi, estimated dose of 7.49 R, to the intestinal wall. The RSO [(Radiation Safety Officer]) reports that standard verification process for patient identification prior to dosage was not followed. Patient and patient's cardiologist have both been notified, no effects of the mis-dose are expected.

"The RSO will provide additional info in the 15 day letter to BRC. Licensing and Technology will be tasked to investigate."

Florida Incident Number FL20-081

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.

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Agreement State Event Number: 54787
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: Alpha-Omega Services, Inc.
Region: 4
City: Vinton,   State: LA
County:
License #: LA-10025-L01, Amedment 33, AI30898
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Thomas Herrity
Notification Date: 07/17/2020
Notification Time: 10:48 [ET]
Event Date: 07/12/2020
Event Time: 00:00 [CDT]
Last Update Date: 07/17/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - SOURCE DAMAGED IN SHIPMENT

The following was received from the Louisiana Department of Environmental Quality via email:

"On July 12, 2020, the Radiation Safety Officer (RSO) contacted the state by voice mail to the Louisiana Department of Environmental Quality/Emergency Response Services Division/Radiation Section to report that a High Dose Rate (HDR) Ir-192 source was damaged in transit with the shipper. The source was being shipped to Providence Regional Cancer Partnership, Rad Oncology Department, 1717 13th Street, Everett, WA 98201. The source serial number is 02-01-2499-001-062320-11518-64. The activity of the Ir-192 source was 11.189 Ci on June 26, 2020 when it was shipped. The source was returned back to Alpha-Omega Services because the HDR drive cable was found damaged and twisted. The transport container had been damaged. The source was found to be one inch high from its designated shielding transportation position. The return survey found the exposure to be 80 mR.hr at surface and 4.0 mR/hr TI. The container had been shipped at a surface reading of 31 mR/hr and a TI of 0.9 mR/hr at one meter."

LA Report Number: LA20200006

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Agreement State Event Number: 54788
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: Mayo Clinic Jacksonville
Region: 1
City: Jacksonville   State: FL
County:
License #: 1812-3
Agreement: Y
Docket:
NRC Notified By: John Williamson
HQ OPS Officer: Thomas Herrity
Notification Date: 07/17/2020
Notification Time: 17:20 [ET]
Event Date: 07/17/2020
Event Time: 00:00 [EDT]
Last Update Date: 07/17/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE ADMINISTERED TO PATIENT

The following was reported by the Florida Bureau of Radiation Control:

"On 7/17/2020 during ablative treatment with Y-90 TheraSpheres to the male patient, it was discovered that only a partial treatment was administered to the patient. 511.6 Gy was prescribed, 358.9 Gy was delivered, for a 70% delivery rate. The event was discovered during a routine check of waste activity. The Radiation Safety Officer (RSO) reports that from initial information from the tech, all procedures were followed. No abnormal events were noted during the procedure. The prescribing physician and patient have been notified. Clinical outcome is expected to be ok. The RSO will phone in more details on Monday as he was working remotely on Friday. A fifteen day letter will follow. Licensing and Technology will be tasked to investigate."

FL incident number: FL20-082

Notified RI and NMSS Events Notification.

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.

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Agreement State Event Number: 54790
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: UTAH CANCER SPECIALISTS
Region: 4
City: Salt Lake City   State: UT
County:
License #: UT 1800491
Agreement: Y
Docket:
NRC Notified By: Phillip Goble
HQ OPS Officer: Thomas Herrity
Notification Date: 07/17/2020
Notification Time: 20:05 [ET]
Event Date: 07/16/2020
Event Time: 00:00 [MDT]
Last Update Date: 07/17/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MISADMINSTRATION OF MEDICAL TREATMENT

The following was received from the State of Utah, Department of Environmental Quality, Division of Waste Management and Radiation Control:

"Misadministration with external beam radiation therapy, the licensee (Utah Cancer Specialists) delivered 300 cGy per site, per day, over two treatments, as follows: Two sites were treated incorrectly at 1000 MDT on July 16, 2020 in the 3rd lumbar area and the right kidney. One site was treated incorrectly at 1530 MDT on July 17, 2020 in the 3rd lumbar area while the right kidney was treated correctly.

"It was discovered by way of a cone beam CT in preparation for the kidney treatment where the misalignment was observed. The misalignment was made due to setting up at incorrect tattoos."

Utah Event Number will be provided in a later report.

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.

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Agreement State Event Number: 54791
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: J.D. Hynes and Associates
Region: 1
City: Princess Anne   State: MD
County:
License #: 45-011-01
Agreement: Y
Docket:
NRC Notified By: Charles Cox
HQ OPS Officer: Kerby Scales
Notification Date: 07/18/2020
Notification Time: 11:17 [ET]
Event Date: 07/17/2020
Event Time: 00:00 [EDT]
Last Update Date: 07/20/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JON LILLIENDAHL (R1DO)
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 TROXLER GAUGE

The following was received by the state of Maryland via email:

"On July 17, 2020 at 2115 EDT the Maryland Radiological Health Program was notified of a lost or stolen portable moisture density gauge. A technician for J. D. Hynes and Associates was at a job site at the University of Maryland Eastern Shore, 30610 College Backbone Road, Princess Anne Maryland. The technician completed the job and was preparing to store the gauge in the transportation case when he was distracted. He then drove the truck approximately 16 miles back to the office at 32185 Beaver Run Drive, Salisbury, MD 21804. The technician discovered the gauge was not in the case. The technician contacted his supervisor and the owner at 1730 EDT and then returned to the job site at approximately 1800 EDT to search for the gauge and discovered the site was locked. The project superintendent was contacted and a key for entry was obtained by the licensee supervisor. Both the licensee supervisor and technician entered the jobsite and searched for the missing gauge and did not locate it there. Then they searched along the travel route independently from each other to try and locate the missing gauge. Both employees searched until approximately 2100 EDT when it got too dark to see. The licensee contacted Wicomico County Police Department and Somerset County Police department and both county fire departments. The gauge was a Troxler 3400 series with 9 mCi Cs-137 and 44 mCi AmBe sources. The serial number is 75791. A reactive inspection will be conducted on Monday July 20, 2020."

* * * UPDATE ON 7/2/2020 AT 1724 EDT FROM ATNATIWOS MESHESHA TO THOMAS KENDZIA * * *

The following update was received via email:

"A portable density gauge was lost from the J.D. Hynes and Associates, Inc. on July 17, 2020 between approximately 14:45 EDT to 15:20 hours EDT. The gauge was identified as Troxler, model 3440P, serial number 75791 with nominal activities of 8 mCi of Cs-137 (on 1/7/2019) and 40 mCi of Am-241:Be (on 2/11/2019). The last leak test was performed on March 6, 2020. The gauge was lost while returning to office from the job-site.

"On July 17, 2020, at approximately 10:00 hours EDT, the density gauge was placed in the tailgate of a pick-up truck by the gauge operator after warm up and daily calibration, and waiting for the day's work at a building construction in the University of Maryland Eastern Shore Campus located at 30610 Collage Backbone Road; Princess Anne, Maryland 25813; in Somerset County. Work was suspended at about 14:45 hours EDT due to water leakages in the underground pipes. The gauge operator proceeded to drive back to the licensee's office located at 32185 Beaver Run Drive, Salisbury, MD 21804, in Wicomico County. After driving for about 25 minutes (about 18 miles) and arriving at the office parking lot the gauge operator realized that the gauge was not placed in its transportation case. The gauge was missing from the bed of the open tailgate of the pick-up truck.

"The event has been reported to the Maryland State Police, in Salisbury; the Incident Number is: 2020-00322775.

"Maryland Department of Environment, Radiological material Division will conduct a reactive investigation.

Notified R1DO (Carfang), NMSS Event Notifications (email) and ILTAB (email).

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

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Agreement State Event Number: 54793
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: Automatic Equipment
Region: 4
City: Pender   State: NE
County:
License #: GL0682
Agreement: Y
Docket:
NRC Notified By: Deb Wilson
HQ OPS Officer: Thomas Kendzia
Notification Date: 07/20/2020
Notification Time: 17:35 [ET]
Event Date: 04/20/2019
Event Time: 00:00 [CDT]
Last Update Date: 07/20/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JAMES DRAKE (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 was received from the state of Nebraska via email and phone:

"Approximately April 2019, a tritium exit sign was thrown away with construction debris while a contractor was cleaning up to remodel from catastrophic flooding in Pender, Nebraska. The sign was discovered missing when inventory was taken 7/17/2020.

"Device Name: RADIOLUMINESCENT SIGN
Manufacturer: Best Lighting
Model Number: SLTURW10
Serial Number: 165713
Radionuclide: H-3
Activity: 7.03 Ci (260.11 GBq)"

Nebraska Incident Report No.: NE200005

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


Page Last Reviewed/Updated Tuesday, July 28, 2020
Tuesday, July 28, 2020