Event Notification Report for October 28, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/27/2020 - 10/28/2020
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State
Event Number: 54969
Rep Org: Spectrum Health
Licensee: Spectrum Health
Region: 3
City: Grand Rapids State: MI
County:
License #: 210024306
Agreement: N
Docket:
NRC Notified By: Evan Boote
HQ OPS Officer: Ossy Font
Licensee: Spectrum Health
Region: 3
City: Grand Rapids State: MI
County:
License #: 210024306
Agreement: N
Docket:
NRC Notified By: Evan Boote
HQ OPS Officer: Ossy Font
Notification Date: 10/28/2020
Notification Time: 16:50 [ET]
Event Date: 10/28/2020
Event Time: 12:00 [EDT]
Last Update Date: 12/02/2020
Notification Time: 16:50 [ET]
Event Date: 10/28/2020
Event Time: 12:00 [EDT]
Last Update Date: 12/02/2020
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
HIRONORI PETERSON (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
HIRONORI PETERSON (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 12/3/2020
EN Revision Text: IODINE-125 SEED INADVERTENTLY LEFT IN PATIENT
The following is a summary of a call with the licensee:
On October 28, 2020, during a routine mammogram, the radiologist found an I-125 seed in the left axilla that was believed to have been previously removed. The 250 microCi seed was implanted on July 5, 2019 as part of a 10 CFR 35.1000 lesion location procedure. It was supposed to have been removed the same day during removal of the lesion.
On the follow-up x-ray of the lesion, the seed was not identified. The radiologist called the operating room, which stated and documented that they had recovered the seed. The licensee noted that there was a second seed implanted in the left breast that was recovered. Both seeds are documented on the same paperwork.
An investigation is in progress, but the licensee believes that the dose to the patient is more than 50 rem to the tissue and total dose delivered differs from the prescribed dose by 20 percent or more.
The patient was informed and no effects are expected.
The licensee will notify the NRC Region 3 Office.
* * * RETRACTION FROM EVAN BOOTE TO DONALD NORWOOD AT 1620 EST ON 12/2/2020 * * *
The following information was received via E-mail:
"Following review of the images and discussion of this case with surgery [personnel], the linear metallic foreign body previously reported as a 'seed' has a high probability of being a vascular surgical clip."
Notified R3DO (Dickson) and NMSS Events Notification E-mail group.
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.
EN Revision Text: IODINE-125 SEED INADVERTENTLY LEFT IN PATIENT
The following is a summary of a call with the licensee:
On October 28, 2020, during a routine mammogram, the radiologist found an I-125 seed in the left axilla that was believed to have been previously removed. The 250 microCi seed was implanted on July 5, 2019 as part of a 10 CFR 35.1000 lesion location procedure. It was supposed to have been removed the same day during removal of the lesion.
On the follow-up x-ray of the lesion, the seed was not identified. The radiologist called the operating room, which stated and documented that they had recovered the seed. The licensee noted that there was a second seed implanted in the left breast that was recovered. Both seeds are documented on the same paperwork.
An investigation is in progress, but the licensee believes that the dose to the patient is more than 50 rem to the tissue and total dose delivered differs from the prescribed dose by 20 percent or more.
The patient was informed and no effects are expected.
The licensee will notify the NRC Region 3 Office.
* * * RETRACTION FROM EVAN BOOTE TO DONALD NORWOOD AT 1620 EST ON 12/2/2020 * * *
The following information was received via E-mail:
"Following review of the images and discussion of this case with surgery [personnel], the linear metallic foreign body previously reported as a 'seed' has a high probability of being a vascular surgical clip."
Notified R3DO (Dickson) and NMSS Events Notification E-mail group.
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: 54970
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: Big Rivers Electric Corporation, DB Wilson Station
Region: 1
City: Robarbs State: KY
County:
License #: 201-208-56
Agreement: Y
Docket:
NRC Notified By: Ashley Marshall
HQ OPS Officer: Donald Norwood
Licensee: Big Rivers Electric Corporation, DB Wilson Station
Region: 1
City: Robarbs State: KY
County:
License #: 201-208-56
Agreement: Y
Docket:
NRC Notified By: Ashley Marshall
HQ OPS Officer: Donald Norwood
Notification Date: 10/29/2020
Notification Time: 11:20 [ET]
Event Date: 10/28/2020
Event Time: 15:11 [CDT]
Last Update Date: 10/29/2020
Notification Time: 11:20 [ET]
Event Date: 10/28/2020
Event Time: 15:11 [CDT]
Last Update Date: 10/29/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
MATT YOUNG (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MATT YOUNG (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - GAUGE SHUTTER FAILURE
The following information was received via E-mail from the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB):
"Big River Electric Corporation reported a shutter failure.
KY RHB was notified via email on October 28, 2020at 1511 EDT) by a
representative from a specifically licensed facility, Big Rivers Electric Corporation, indicating that one fixed gauging device (Kay Ray Model 7062P, Serial Number 8555), containing a 10 mCi Cs-137 source located in the Reid/Green/HMP&L Station II had a shutter malfunction. The source was found to have a broken shutter arm. The gauge has been left in place and a contractor will be scheduled to service the gauge. The Radiation Safety Officer (RSO) has notified the production manager and production leaders to ensure they are aware of the issue. Reporting criteria in 10 CFR 30.50(b)(2)."
Kentucky Event Report ID Number: KY200005
The following information was received via E-mail from the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB):
"Big River Electric Corporation reported a shutter failure.
KY RHB was notified via email on October 28, 2020at 1511 EDT) by a
representative from a specifically licensed facility, Big Rivers Electric Corporation, indicating that one fixed gauging device (Kay Ray Model 7062P, Serial Number 8555), containing a 10 mCi Cs-137 source located in the Reid/Green/HMP&L Station II had a shutter malfunction. The source was found to have a broken shutter arm. The gauge has been left in place and a contractor will be scheduled to service the gauge. The Radiation Safety Officer (RSO) has notified the production manager and production leaders to ensure they are aware of the issue. Reporting criteria in 10 CFR 30.50(b)(2)."
Kentucky Event Report ID Number: KY200005