Event Notification Report for June 04, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/03/2021 - 06/04/2021
Agreement State
Event Number: 55291
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: RAM Services, Inc.
Region: 3
City: Two Rivers State: WI
County:
License #: 071-1234-01
Agreement: Y
Docket:
NRC Notified By: Megan Shober
HQ OPS Officer: Bethany Cecere
Licensee: RAM Services, Inc.
Region: 3
City: Two Rivers State: WI
County:
License #: 071-1234-01
Agreement: Y
Docket:
NRC Notified By: Megan Shober
HQ OPS Officer: Bethany Cecere
Notification Date: 06/04/2021
Notification Time: 16:47 [ET]
Event Date: 06/04/2021
Event Time: 00:00 [CDT]
Last Update Date: 06/18/2021
Notification Time: 16:47 [ET]
Event Date: 06/04/2021
Event Time: 00:00 [CDT]
Last Update Date: 06/18/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
DICKSON, BILLY (R3)
ILTAB, (EMAIL)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
CNSC (CANADA), - (EMAIL)
DICKSON, BILLY (R3)
ILTAB, (EMAIL)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
CNSC (CANADA), - (EMAIL)
EN Revision Imported Date: 7/16/2021
EN Revision Text: AGREEMENT STATE REPORT - MISSING RADIOACTIVE MATERIAL SHIPMENT
The following report from the state of Wisconsin was received by email:
"On June 4, 2021 the licensee reported to the Department [of Health Services] that a package containing 25 Curies of Cs-137 had been shipped from Wisconsin on April 16, 2021 and did not arrive at its destination in California. The last known location of the package was in Chicago, Illinois on April 22, 2021. The licensee is following up with the common carrier, but to date the package has not been located."
WI Event Report ID No.: WI210004
* * * UPDATE ON 06/18/2021 AT 1351 FROM DIEGO SAENZ TO LLOYD DESOTELL * * *
The following report update from the state of Wisconsin was received by email:
"The package arrived at its destination on June 7, 2021. The package was completely intact, including seal, with no signs of damage. When the licensee who offered the package for shipment contacted the common carrier, the licensee was not provided with any details of problems during shipment. However, the package was located and promptly delivered. The Department considers this event closed."
Notified R3DO (Hills), NMSS Events Notification (email), ILTAB (email) and CNSC Canada (email).
THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
EN Revision Text: AGREEMENT STATE REPORT - MISSING RADIOACTIVE MATERIAL SHIPMENT
The following report from the state of Wisconsin was received by email:
"On June 4, 2021 the licensee reported to the Department [of Health Services] that a package containing 25 Curies of Cs-137 had been shipped from Wisconsin on April 16, 2021 and did not arrive at its destination in California. The last known location of the package was in Chicago, Illinois on April 22, 2021. The licensee is following up with the common carrier, but to date the package has not been located."
WI Event Report ID No.: WI210004
* * * UPDATE ON 06/18/2021 AT 1351 FROM DIEGO SAENZ TO LLOYD DESOTELL * * *
The following report update from the state of Wisconsin was received by email:
"The package arrived at its destination on June 7, 2021. The package was completely intact, including seal, with no signs of damage. When the licensee who offered the package for shipment contacted the common carrier, the licensee was not provided with any details of problems during shipment. However, the package was located and promptly delivered. The Department considers this event closed."
Notified R3DO (Hills), NMSS Events Notification (email), ILTAB (email) and CNSC Canada (email).
THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Agreement State
Event Number: 55296
Rep Org: South Carolina Department of Health
Licensee: Prisma Health Greenville Memorial Hospital
Region: 1
City: Greenville State: SC
County:
License #: L275
Agreement: Y
Docket:
NRC Notified By: Andrew Roxburgh
HQ OPS Officer: Brian P. Smith
Licensee: Prisma Health Greenville Memorial Hospital
Region: 1
City: Greenville State: SC
County:
License #: L275
Agreement: Y
Docket:
NRC Notified By: Andrew Roxburgh
HQ OPS Officer: Brian P. Smith
Notification Date: 06/08/2021
Notification Time: 06:34 [ET]
Event Date: 06/04/2021
Event Time: 12:00 [EDT]
Last Update Date: 06/08/2021
Notification Time: 06:34 [ET]
Event Date: 06/04/2021
Event Time: 12:00 [EDT]
Last Update Date: 06/08/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
FERDAS, MARC (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
FERDAS, MARC (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 7/8/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT UNDERDOSE
The following event was received from the South Carolina Department of Health [the Department] via email:
"The licensee notified the Department on June 7, 2021 at 1300 [EDT] that it had determined at 1200 [EDT] a medical event had occurred because of a Y-90 Therasphere procedure that occurred on June 4, 2021. The licensee is reporting that the administered dose differed from the prescribed dose by more that 20 percent. The written directive specified that the patient was to be administered with 135.5 mCi of Y-90 Therasphere to the left lobe of the liver. During the procedure it was discovered that there was an apparent leak in the microcatheter. The dose delivered calculated to be less than 93 mCi. The remainder of the dose had leaked onto the floor. The licensee has decontaminated the room. The On-call Duty Officer is meeting with the licensee's Radiation Safety Officer on June 8, 2021 to investigate this incident. This is an initial notification and further updates will be forthcoming once the investigation is complete."
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 UNDERDOSE
The following event was received from the South Carolina Department of Health [the Department] via email:
"The licensee notified the Department on June 7, 2021 at 1300 [EDT] that it had determined at 1200 [EDT] a medical event had occurred because of a Y-90 Therasphere procedure that occurred on June 4, 2021. The licensee is reporting that the administered dose differed from the prescribed dose by more that 20 percent. The written directive specified that the patient was to be administered with 135.5 mCi of Y-90 Therasphere to the left lobe of the liver. During the procedure it was discovered that there was an apparent leak in the microcatheter. The dose delivered calculated to be less than 93 mCi. The remainder of the dose had leaked onto the floor. The licensee has decontaminated the room. The On-call Duty Officer is meeting with the licensee's Radiation Safety Officer on June 8, 2021 to investigate this incident. This is an initial notification and further updates will be forthcoming once the investigation is complete."
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.