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Event Notification Report for August 06, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/5/2020 - 8/6/2020

** EVENT NUMBERS **

Agreement State	Event Number: 54778
Rep Org: CALIFORNIA RADIATION CONTROL PRGM Licensee: RMA Group Region: 4 City: Rancho Cucamonga State: CA County: License #: 071420 Agreement: Y Docket: NRC Notified By: L. Robert Greger HQ OPS Officer: Ossy Font	Notification Date: 07/14/2020 Notification Time: 23:51 [ET] Event Date: 07/13/2020 Event Time: 06:00 [PDT] Last Update Date: 07/15/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): VINCENT GADDY (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL) - CNSNS (MEXICO) (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following was received from the California Department of Public Health via email:

"A Troxler moisture density gauge (model 3430, serial # 31716) was reported stolen Monday morning at approximately 0600 PDT from the bed of an employee's vehicle while the vehicle was parked for 1-2 hours outside the employee's residence in Moreno Valley, CA. The gauge contains approximately 0.3 GBq (8 mCi) of Cs-137 and 1.50 GBq (40 mCi) of Am-241. The gauge was reportedly picked up earlier that morning at the licensee's office in Rancho Cucamonga, and left appropriately chained/locked in the back of the vehicle at the employee's residence before leaving for a work location. The theft was reported to the Moreno Valley Police Department (police report #MV201950058 taken by Officer Flores). A reward will be advertised for the return of the gauge."

California 5010 NUMBER: 071420

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: 54804
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY Licensee: KishHealth System Region: 3 City: Dekalb State: IL County: License #: IL-02097-01 Agreement: Y Docket: NRC Notified By: Gary Forsee HQ OPS Officer: Thomas Herrity	Notification Date: 07/29/2020 Notification Time: 13:43 [ET] Event Date: 07/28/2020 Event Time: 00:00 [CDT] Last Update Date: 07/29/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): MICHAEL KUNOWSKI (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT- PATIENT UNDERDOSE

The following was received from the Illinois Emergency Management Agency (IEMA) via email:

"KishHealth System in Dekalb, IL (d/b/a Kishwaukee Community Hospital) contacted the IEMA at approximately 1100 CDT on 7/29/20 to report a patient scheduled to receive Y-90 microsphere therapy for hepatocellular cancer received only 58% of the dose prescribed in the written directive. While investigation is ongoing, the reportable underdose is based on licensee's pre and post-administration measurements of the dose vial and waste container, respectively.

"IEMA staff have contacted the licensee and are seeking additional information on post-administration imaging, status of patient/referring AU notification, the nature of the written directive (i.e., was this a fractionated dose), and the members of the treatment team. These factors, among others, will determine regulatory compliance as well as patient impact. Therefore, this report will be updated as information becomes available. IEMA is dispatching staff today (7/29/20) for a reactionary inspection. The reporting requirements for the licensee, as specified in 32 Ill. Adm. Code 335.1080(c) were met, and the licensee is aware of the need for a written report within 15 days."

Illinois item number: IL200013

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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