Event Notification Report for April 04, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/03/2021 - 04/04/2021
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State
Event Number: 55170
Rep Org: Good Samaritan Hospital
Licensee: Good Samaritan Hospital
Region: 3
City: Vincennes State: IN
County:
License #: 13-01787-01
Agreement: N
Docket:
NRC Notified By: Brook Strahle
HQ OPS Officer: Brian P. Smith
Licensee: Good Samaritan Hospital
Region: 3
City: Vincennes State: IN
County:
License #: 13-01787-01
Agreement: N
Docket:
NRC Notified By: Brook Strahle
HQ OPS Officer: Brian P. Smith
Notification Date: 04/04/2021
Notification Time: 14:57 [ET]
Event Date: 04/04/2021
Event Time: 11:30 [EDT]
Last Update Date: 04/05/2021
Notification Time: 14:57 [ET]
Event Date: 04/04/2021
Event Time: 11:30 [EDT]
Last Update Date: 04/05/2021
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):
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
KEVIN WILLIAMS (NMSS)
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
KEVIN WILLIAMS (NMSS)
EN Revision Imported Date: 5/5/2021
EN Revision Text: PATIENT RECEIVES WRONG DOSE
The following is a summary from a phone call and subsequent e-mail from the technologist at the Good Samaritan Hospital in Vincennes, Indiana:
On Sunday, April 4th, 2021 at approximately 1130 EDT, a reportable event occurred when the technologist was called in to administer injections for two patients. The first patient was to have a lung scan. Instead of injecting the patient with Tc99m MAA for a lung perfusion, the technologist injected him with Tc99m Choletec that was to be used for the second patient. Both the lung dose and the gallbladder dose were calibrated for the same time and both were 5 mCi doses. The technologist picked up the wrong dose but did not double check the syringe sticker before administration. The patient suffered no visible harm and picked up an additional exposure from the 5.23 mCi of Tc99m Choletec and a delay in completing the exam since pictures would not be diagnostic if done before the choletec has had the chance to dissipate. The technologist notified the NRC Operations Center and completed an incident report for the hospital. The technologist plans to notify her supervisor, the Radiation Safety Officer, the patient's nurse, patient, and radiologist.
* * * RETRACTION ON 4/5/21 AT 1519 EDT FROM BROOK STRAHLE TO BETHANY CECERE * * *
On further evaluation, this event did not meet reportability requirements.
Notified R3DO (Pelke), NMSS (Williams), and NMSS Events Notification (by 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: PATIENT RECEIVES WRONG DOSE
The following is a summary from a phone call and subsequent e-mail from the technologist at the Good Samaritan Hospital in Vincennes, Indiana:
On Sunday, April 4th, 2021 at approximately 1130 EDT, a reportable event occurred when the technologist was called in to administer injections for two patients. The first patient was to have a lung scan. Instead of injecting the patient with Tc99m MAA for a lung perfusion, the technologist injected him with Tc99m Choletec that was to be used for the second patient. Both the lung dose and the gallbladder dose were calibrated for the same time and both were 5 mCi doses. The technologist picked up the wrong dose but did not double check the syringe sticker before administration. The patient suffered no visible harm and picked up an additional exposure from the 5.23 mCi of Tc99m Choletec and a delay in completing the exam since pictures would not be diagnostic if done before the choletec has had the chance to dissipate. The technologist notified the NRC Operations Center and completed an incident report for the hospital. The technologist plans to notify her supervisor, the Radiation Safety Officer, the patient's nurse, patient, and radiologist.
* * * RETRACTION ON 4/5/21 AT 1519 EDT FROM BROOK STRAHLE TO BETHANY CECERE * * *
On further evaluation, this event did not meet reportability requirements.
Notified R3DO (Pelke), NMSS (Williams), and NMSS Events Notification (by 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.
Agreement State
Event Number: 55171
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Universal Pressure Pumping Inc
Region: 4
City: Cleburne State: TX
County: La Salle
License #: L06871
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Bethany Cecere
Licensee: Universal Pressure Pumping Inc
Region: 4
City: Cleburne State: TX
County: La Salle
License #: L06871
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Bethany Cecere
Notification Date: 04/05/2021
Notification Time: 15:19 [ET]
Event Date: 04/04/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/05/2021
Notification Time: 15:19 [ET]
Event Date: 04/04/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/05/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
KOZAL, JASON (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
KOZAL, JASON (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 5/5/2021
EN Revision Text: AGREEMENT STATE REPORT - FAILED SHUTTER HANDLE ON NUCLEAR GAUGE
"On April 5, 2021, the licensee reported that on April 4, 2021, the roll pin in the shutter handle on a Berthold Model 8010 density gauge containing 20 milliCuries of cesium-137 had failed and the shutter handle came off. The gauge had been mounted on a pipe near the well head on a well in La Salle County, Texas. The licensee is authorized to replace the roll pin so one of its trained technicians responded to the site and removed the gauge and repaired the roll pin. The technician found the shutter was closed when he surveyed prior to beginning work. The licensee also reported the technician found that the nuts had backed off of the bolts where the gauge was mounted to the pipe, so the gauge was not snug to the pipe. The licensee contacted Berthold to discuss effects of vibration as it pertains to this event (and potential effect for its other gauges mounted similarly) as well as the corrosion that was observed on roll pin(s). The licensee's determination was that there would not have been any exposures as a result of this event. The licensee will keep the gauge in storage until it can complete an evaluation of the gauge mounting location and the roll pin type for this and its other gauges. An investigation into this event is ongoing. Further information will be provided as it is obtained in accordance with SA-300.
"Device/Source Information:
"Berthold Model 8010 SN: 10455
"20 milliCurie cesium-137 source: SN: 0330/12 (Eckert-Zigler Model CS7.P02)"
Texas Incident Number: 9836
EN Revision Text: AGREEMENT STATE REPORT - FAILED SHUTTER HANDLE ON NUCLEAR GAUGE
"On April 5, 2021, the licensee reported that on April 4, 2021, the roll pin in the shutter handle on a Berthold Model 8010 density gauge containing 20 milliCuries of cesium-137 had failed and the shutter handle came off. The gauge had been mounted on a pipe near the well head on a well in La Salle County, Texas. The licensee is authorized to replace the roll pin so one of its trained technicians responded to the site and removed the gauge and repaired the roll pin. The technician found the shutter was closed when he surveyed prior to beginning work. The licensee also reported the technician found that the nuts had backed off of the bolts where the gauge was mounted to the pipe, so the gauge was not snug to the pipe. The licensee contacted Berthold to discuss effects of vibration as it pertains to this event (and potential effect for its other gauges mounted similarly) as well as the corrosion that was observed on roll pin(s). The licensee's determination was that there would not have been any exposures as a result of this event. The licensee will keep the gauge in storage until it can complete an evaluation of the gauge mounting location and the roll pin type for this and its other gauges. An investigation into this event is ongoing. Further information will be provided as it is obtained in accordance with SA-300.
"Device/Source Information:
"Berthold Model 8010 SN: 10455
"20 milliCurie cesium-137 source: SN: 0330/12 (Eckert-Zigler Model CS7.P02)"
Texas Incident Number: 9836