Event Notification Report for April 14, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/13/2021 - 04/14/2021
Agreement State
Event Number: 55193
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Columbia Hospital At Medical City Dallas
Region: 4
City: Dallas State: TX
County:
License #: L 01976
Agreement: Y
Docket:
NRC Notified By: Randal Redd
HQ OPS Officer: Joanna Bridge
Licensee: Columbia Hospital At Medical City Dallas
Region: 4
City: Dallas State: TX
County:
License #: L 01976
Agreement: Y
Docket:
NRC Notified By: Randal Redd
HQ OPS Officer: Joanna Bridge
Notification Date: 04/14/2021
Notification Time: 13:15 [ET]
Event Date: 04/14/2021
Event Time: 08:45 [CDT]
Last Update Date: 04/14/2021
Notification Time: 13:15 [ET]
Event Date: 04/14/2021
Event Time: 08:45 [CDT]
Last Update Date: 04/14/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PICK, GREG (R4DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
PICK, GREG (R4DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
EN Revision Imported Date: 5/14/2021
EN Revision Text: AGREEMENT STATE REPORT - PATIENT RECEIVES WRONG DOSE
The following was received via e-mail from the State of Texas:
"On April 14, 2021, the licensee reported that a patient who was to receive 200 micro Ci of I-123 as a diagnostic procedure instead received 150 milli Ci I-131. The patient apparently left the hospital but is on their way back to receive [potassium iodine, (KI)] KI treatment and will remain in the hospital. The licensee will conduct investigation into how incident occurred and what the dose to the patient was.
"Additional information will be provided as it is received in accordance with SA-300.
"Texas Incident #: 9840"
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 - PATIENT RECEIVES WRONG DOSE
The following was received via e-mail from the State of Texas:
"On April 14, 2021, the licensee reported that a patient who was to receive 200 micro Ci of I-123 as a diagnostic procedure instead received 150 milli Ci I-131. The patient apparently left the hospital but is on their way back to receive [potassium iodine, (KI)] KI treatment and will remain in the hospital. The licensee will conduct investigation into how incident occurred and what the dose to the patient was.
"Additional information will be provided as it is received in accordance with SA-300.
"Texas Incident #: 9840"
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: 55194
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Acuren Inspection INC
Region: 4
City: La Porte State: TX
County:
License #: L 01774
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Joanna Bridge
Licensee: Acuren Inspection INC
Region: 4
City: La Porte State: TX
County:
License #: L 01774
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Joanna Bridge
Notification Date: 04/14/2021
Notification Time: 17:44 [ET]
Event Date: 04/14/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/14/2021
Notification Time: 17:44 [ET]
Event Date: 04/14/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/14/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PICK, GREG (R4DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
PICK, GREG (R4DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 5/14/2021
EN Revision Text: AGREEMENT STATE - BROKEN RADIOGRAPHY CAMERA
The following was received via e-mail from the Texas Department of State Health Services:
"On April 14, 2021, the licensee reported to the agency [Texas Department of State Health Services] that one of its crews had been unable to retract a source while working at a temporary job site. They were using a QSA Delta 880 exposure device with a 96.7 curie iridium-192 source. The radiographers were cranking in the source and it did not feel right but it retracted and locked in inside the camera. They performed a survey of the camera and guide tube and found the source was in the fully shielded position. They cranked out for the next shot without issue but when they attempted to retract the source it was no longer on the end of the drive cable. The radiographers set a barricade and called the radiation safety officer (RSO). The RSO responded and performed a source retrieval. His electronic dosimeter indicated he received 70 mrem and there were no other exposures as a result of this event. The RSO reported that the drive cable had broken below the shank. The equipment will be sent to the manufacturer for evaluation. More information will be provided as it is obtained in accordance with SA-300.
"Equipment information:
QSA Delta 880 exposure device SN: D8849
96.7 curie iridium-192 source SN: 30413M
"Texas Incident no.: 9841"
EN Revision Text: AGREEMENT STATE - BROKEN RADIOGRAPHY CAMERA
The following was received via e-mail from the Texas Department of State Health Services:
"On April 14, 2021, the licensee reported to the agency [Texas Department of State Health Services] that one of its crews had been unable to retract a source while working at a temporary job site. They were using a QSA Delta 880 exposure device with a 96.7 curie iridium-192 source. The radiographers were cranking in the source and it did not feel right but it retracted and locked in inside the camera. They performed a survey of the camera and guide tube and found the source was in the fully shielded position. They cranked out for the next shot without issue but when they attempted to retract the source it was no longer on the end of the drive cable. The radiographers set a barricade and called the radiation safety officer (RSO). The RSO responded and performed a source retrieval. His electronic dosimeter indicated he received 70 mrem and there were no other exposures as a result of this event. The RSO reported that the drive cable had broken below the shank. The equipment will be sent to the manufacturer for evaluation. More information will be provided as it is obtained in accordance with SA-300.
"Equipment information:
QSA Delta 880 exposure device SN: D8849
96.7 curie iridium-192 source SN: 30413M
"Texas Incident no.: 9841"