Event Notification Report for January 29, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/28/2021 - 01/29/2021
Agreement State
Event Number: 55090
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: Cleveland Clinic Weston
Region: 1
City: Weston State: FL
County:
License #: 3748-1
Agreement: Y
Docket:
NRC Notified By: Paul Norman
HQ OPS Officer: Kerby Scales
Licensee: Cleveland Clinic Weston
Region: 1
City: Weston State: FL
County:
License #: 3748-1
Agreement: Y
Docket:
NRC Notified By: Paul Norman
HQ OPS Officer: Kerby Scales
Notification Date: 01/29/2021
Notification Time: 16:38 [ET]
Event Date: 01/29/2021
Event Time: 00:00 [EST]
Last Update Date: 01/29/2021
Notification Time: 16:38 [ET]
Event Date: 01/29/2021
Event Time: 00:00 [EST]
Last Update Date: 01/29/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
WERKHEISER, DAVE (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
WERKHEISER, DAVE (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 2/7/2021
EN Revision Text: AGREEMENT STATE REPORT - LEAKING SEALED SOURCE
The following was received from the Florida Bureau of Radiation Control (BRC) via email:
"The [licensee] reported a failed leak test of a cesuim-137 (activity 197.2 microcuries - January 1, 2006) `E' vial. The test was conducted January 27, 2021. The leaking source has been double-bagged and is being stored in a lead-shield container while awaiting an investigation and eventual transfer for disposal. No detectable contamination was found in the storage area, on personnel, in work spaces, nor on equipment. A formal report is forthcoming. The BRC has been contacted and tasked to investigate."
Florida Incident Number: FL21-013
EN Revision Text: AGREEMENT STATE REPORT - LEAKING SEALED SOURCE
The following was received from the Florida Bureau of Radiation Control (BRC) via email:
"The [licensee] reported a failed leak test of a cesuim-137 (activity 197.2 microcuries - January 1, 2006) `E' vial. The test was conducted January 27, 2021. The leaking source has been double-bagged and is being stored in a lead-shield container while awaiting an investigation and eventual transfer for disposal. No detectable contamination was found in the storage area, on personnel, in work spaces, nor on equipment. A formal report is forthcoming. The BRC has been contacted and tasked to investigate."
Florida Incident Number: FL21-013
Agreement State
Event Number: 55091
Rep Org: ARIZONA DEPT OF HEALTH SERVICES
Licensee: Palo Verde Cancer Center
Region: 4
City: Glendale State: AZ
County:
License #: 07-694
Agreement: Y
Docket:
NRC Notified By: Brian D. Goretzki
HQ OPS Officer: Howie Crouch
Licensee: Palo Verde Cancer Center
Region: 4
City: Glendale State: AZ
County:
License #: 07-694
Agreement: Y
Docket:
NRC Notified By: Brian D. Goretzki
HQ OPS Officer: Howie Crouch
Notification Date: 01/30/2021
Notification Time: 08:57 [ET]
Event Date: 01/29/2021
Event Time: 00:00 [MST]
Last Update Date: 01/30/2021
Notification Time: 08:57 [ET]
Event Date: 01/29/2021
Event Time: 00:00 [MST]
Last Update Date: 01/30/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
DRAKE, JAMES (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
DRAKE, JAMES (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 2/7/2021
EN Revision Text:
AGREEMENT STATE REPORT - TREATMENT AREA LARGER THAN PRESCRIBED
The following information was received from the Arizona Department of Health Services (the Department) via email:
"The Department received notification from the licensee on January 29, at approximately 1940 [MDT], about a medical event involving a Varian Gamma Medplus iX, HDR [high dose rate] afterloader brachytherapy unit with a 5.853 curie iridium-192 source. A patient was being treated for skin cancer on the right leg with a Varian surface applicator utilizing a 35 mm cone. The prescription was for 5000 cGy in 20 fractions of 250 cGy per fraction. The patient was treated at the correct treatment site but without the 35 mm cone inserted into the applicator for one fraction. The Department has requested additional information and continues to investigate the event."
Arizona Incident No. 21-001
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:
AGREEMENT STATE REPORT - TREATMENT AREA LARGER THAN PRESCRIBED
The following information was received from the Arizona Department of Health Services (the Department) via email:
"The Department received notification from the licensee on January 29, at approximately 1940 [MDT], about a medical event involving a Varian Gamma Medplus iX, HDR [high dose rate] afterloader brachytherapy unit with a 5.853 curie iridium-192 source. A patient was being treated for skin cancer on the right leg with a Varian surface applicator utilizing a 35 mm cone. The prescription was for 5000 cGy in 20 fractions of 250 cGy per fraction. The patient was treated at the correct treatment site but without the 35 mm cone inserted into the applicator for one fraction. The Department has requested additional information and continues to investigate the event."
Arizona Incident No. 21-001
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.