Event Notification Report for March 18, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/17/2021 - 03/18/2021
EVENT NUMBERS
55145
55145
Agreement State
Event Number: 55145
Rep Org: NORTH DAKOTA DEPARTMENT OF ENV QUAL
Licensee: Sanford Medical Center
Region: 4
City: Fargo State: ND
County:
License #: 33-10227-02
Agreement: Y
Docket:
NRC Notified By: Brooke Olson
HQ OPS Officer: Lloyd Desotell
Licensee: Sanford Medical Center
Region: 4
City: Fargo State: ND
County:
License #: 33-10227-02
Agreement: Y
Docket:
NRC Notified By: Brooke Olson
HQ OPS Officer: Lloyd Desotell
Notification Date: 03/19/2021
Notification Time: 12:05 [ET]
Event Date: 03/18/2021
Event Time: 00:00 [MDT]
Last Update Date: 04/14/2021
Notification Time: 12:05 [ET]
Event Date: 03/18/2021
Event Time: 00:00 [MDT]
Last Update Date: 04/14/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 5/14/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT (INCORRECT DOSE LOCATION)
The following report was received from the state of North Dakota Department of Environmental Quality via email:
"Received a phone call at 1600 [CST] on Thursday March 18 that a PET/CT patient was injected with 10 milliCuries of Fluorine-18 and it was found that all of the injected Fluorine-18 had infiltrated in the arm of the patient [rather than being dispersed throughout the body]. Patient's arm was imaged by PET scanner to confirm dose was in fact infiltrated in the arm. Dose calculations are being performed by licensee to determine the dose to the patient's skin. "
ND NMED Event # ND210001
* * * RETRACTION ON 14 APRIL 2021 AT 1522 EDT FROM BROOKE OLSON TO JOANNA BRIDGE * * *
The following is a summary of a phone conversation with Brooke Olson from the North Dakota Department of Environmental Quality:
After calculations were performed, it was determined that the event did not meet the reporting requirements of a medical event and is being retracted.
Notified: R4DO (Pick) and NMSS (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.
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT (INCORRECT DOSE LOCATION)
The following report was received from the state of North Dakota Department of Environmental Quality via email:
"Received a phone call at 1600 [CST] on Thursday March 18 that a PET/CT patient was injected with 10 milliCuries of Fluorine-18 and it was found that all of the injected Fluorine-18 had infiltrated in the arm of the patient [rather than being dispersed throughout the body]. Patient's arm was imaged by PET scanner to confirm dose was in fact infiltrated in the arm. Dose calculations are being performed by licensee to determine the dose to the patient's skin. "
ND NMED Event # ND210001
* * * RETRACTION ON 14 APRIL 2021 AT 1522 EDT FROM BROOKE OLSON TO JOANNA BRIDGE * * *
The following is a summary of a phone conversation with Brooke Olson from the North Dakota Department of Environmental Quality:
After calculations were performed, it was determined that the event did not meet the reporting requirements of a medical event and is being retracted.
Notified: R4DO (Pick) and NMSS (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.