Event Notification Report for May 12, 2021

EN Revision Imported Date: 5/12/2021

EN Revision Text: AGREEMENT STATE REPORT - MISADMINISTRATION OF PHARMACEUTICAL

The following report was received via fax from the Alabama Department of Public Health, Office of Radiation Control

"On April 28, 2021, Alabama licensee Druid City Hospital (DCH) Regional Medical Center, RML 219, reported that a patient received an estimated 119.49 millicuries of sodium pertechnetate on April 27, 2021 around 12:00pm [CDT]. The patient was prescribed 30 millicuries of sestamibi. The effective dose was estimated to be 5747.4 mrem (5.7474 rem). The Agency is continuing to investigate."

Alabama Event 21-15

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 Imported Date: 5/12/2021

EN Revision Text: AGREEMENT STATE REPORT - TROXLER GAUGE HIT BY CONSTRUCTION GRADER.

The following was reported by the State of Nevada:

"An authorized user (AU) and portable nuclear gauge were run over by grader while using the gauge. The AU and gauge were blocked from the driver's view by the grader wheel. The AU was exposed to the source for approximately thirty (30) minutes while the source rod was extended. The source rod remained intact however it cannot be pulled back into the shielded position due to the bent source rod.
The radiation safety officer (RSO) placed the source rod into a concrete cylinder to limit the dose to responders. Then the gauge and the cylinder were placed in a fifty-five (55) gallon drum. It was sealed and transported back to the storage facility. The licensee is working with Troxler to make arrangements to return the gauge.

"On contact readings of the transport drum were no higher than 0.6 mR/hr and 0.260 mR/hr at one meter. No contamination was found on the gauge, shipping container or the RSO's hands.

"The licensee has been requested to ship the AU's dosimeter for immediate processing due to the long exposure. Will update AU exposure once results are received. The AU is expected to recover."

Nevada Item Number: NV210006.

* * * UPDATE ON 5/6/21 AT 1149 EDT FROM COREY CREVELING TO THOMAS HERRITY * * *

The following information was received from the State of Nevada via E-mail:

"The State of Nevada Radiation Control Program received notification that the authorized user reported in Event Number 55233, that was struck by a grader while using a portable gauge died on May 5, 2021."

Nevada Item Number: NV210006.

Notified R4DO (Deese), IRMOC (Gott) and NMSS Coordinator (Rivera-Capella). NMSS Events Notification via email.

* * * UPDATE ON 5/6/21 AT 1909 EDT FROM COREY CREVELING TO THOMAS HERRITY * * *

The following information was received from the State of Nevada via E-mail:

"This is to follow up from our discussion earlier this morning and I have attached the AU's dosimetry report as requested. Based on the report, exposure did not contribute to his death, and the Nevada Radiation Control Program will not be issuing a press release. As of right now the cause of death remains related to injuries from being struck by the road grader."

The radiation dosimetry report for period April 4, 2021 to June 30, 2021 showed 3 mRem.

Notified R4DO (Deese); IRMOC (Gott), NMSS (Rivera-Capella), and NMSS Events Notification via email.

EN Revision Imported Date: 5/12/2021

EN Revision Text: AGREEMENT STATE REPORT - NUCLEAR GAUGE SHUTTER ARM FAILURE

The following was received from the Texas Department of State Health Services (the Agency) by email:

"On May 5, 2021, the Agency was notified by the licensee that while performing fracking operations at a well site, the shutter operating arm roll pin fell out of a Berthold model 8010 nuclear gauge. The gauge contains a 20 milliCurie cesium - 137 source. The licensee was able to close the shutter. The licensee stated that the gauge roll pin had previously failed in November of 2020 (EN 54992). The licensee stated they had been experiencing problems with the gauge roll pins after changing the position of the gauge during operation making it closer to the pump and exposing it to greater vibration. This was the fourth event reported by the licensee since November 2020. The licensee stated that they have begun changing the location of the gauge by moving it further from the pump and therefore exposing it to less vibration. The licensee stated that they had discussed the current location with the manufacturer and was told by the manufacturer that the gauge should not be affected. The roll pin is 5/32 inches in diameter and is friction fitted into the operating rod and held in place by friction. No exposures occurred due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: I-9846

EN Revision Imported Date: 5/12/2021

EN Revision Text: AGREEMENT STATE REPORT - MISADMINISTRATION DURING BRACHYTHERAPY TREATMENT

The following was received from the State of Florida:

"Administration of radiation and subsequent received dose to an incorrect area of patient during a gynecological brachytherapy treatment on 5/4/21. The Radiation Safety Officer (RSO) reported that a source transfer tube of incorrect length (approximately 12 cm too long) was used resulting in exposure misadministration.

"The patient was notified. The attending physician and RSO advised patient that no adverse health effects are expected.

"Source Serial #: 02-01-3155-001-020321-11408-84

"Maximum Dose Received: 8-9 Gray, Shallow."

Florida Incident Number: FL21-056


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 Imported Date: 5/12/2021

EN Revision Text: FITNESS FOR DUTY - DISCOVERED VULNERABILITY IN FITNESS FOR DUTY PROGRAM

On May 10, 2021, Callaway determined that a violation of 10 CFR 26.4(c) occurred. A licensee employee was assigned to perform Emergency Response Organization (ERO) duties that required that employee to be subject to the Fitness for Duty (FFD) program. However, the individual had been removed from the FFD program. The individual's unescorted access to the plant had been temporarily removed, but the individual was still required to report to the Emergency Operations Facility in accordance with the emergency plan procedures. The individual's ERO qualification has been deactivated. A review determined that this condition did not apply to any other ERO responders. This discovery is reported pursuant to 10 CFR 26.719(b)(4).

The NRC Senior Resident Inspector has been notified of the event.