Event Notification Report for July 01, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/30/2021 - 07/01/2021
Agreement State
Event Number: 55334
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: John Muir Medical Center
Region: 4
City: Concord State: CA
County:
License #: 0729-07
Agreement: Y
Docket:
NRC Notified By: K. Arunika Hewadikaram
HQ OPS Officer: Bethany Cecere
Licensee: John Muir Medical Center
Region: 4
City: Concord State: CA
County:
License #: 0729-07
Agreement: Y
Docket:
NRC Notified By: K. Arunika Hewadikaram
HQ OPS Officer: Bethany Cecere
Notification Date: 07/01/2021
Notification Time: 20:17 [ET]
Event Date: 07/01/2021
Event Time: 00:00 [PDT]
Last Update Date: 07/01/2021
Notification Time: 20:17 [ET]
Event Date: 07/01/2021
Event Time: 00:00 [PDT]
Last Update Date: 07/01/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
WERNER, GREG (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
WERNER, GREG (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 7/30/2021
EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDER DOSE
The following was submitted by the California Department of Public Health - Radiologic Health Branch (RHB) by email:
"On 07/01/2021, licensee contacted RHB to report a medical event associated with Ytrrium-90 TheraSpheres. On the written directive, Authorized User's (AU) desired dose to the target volume was 800 Gy. Based on the calculations, radiation dose delivered was 400.2 Gy.
"During the procedure, patient was infused with 1.067 Gbq of Y-90. Upon completion of the infusion, based on residual exposure readings, it was determined that an estimated dose of 0.522 Gbq was delivered to the patient, 50% of the written directive. Given the Y-90 supply vial was empty, based on the 0.00 mR/hr reading on the adjacent dosimeter, it has been speculated that Y-90 was held up in the micro-catheter. AU suspects this high residual waste reading was due to a slower infusion of the treatment dose and flushing fluid; this will be determined at a later date when the yttrium-90 waste material has decayed and can be safely broken down with individual components measured. The referring physician (AU), informed the patient of the event.
"RHB will be following up on the medical event."
CA 5010 Number: 070121
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 UNDER DOSE
The following was submitted by the California Department of Public Health - Radiologic Health Branch (RHB) by email:
"On 07/01/2021, licensee contacted RHB to report a medical event associated with Ytrrium-90 TheraSpheres. On the written directive, Authorized User's (AU) desired dose to the target volume was 800 Gy. Based on the calculations, radiation dose delivered was 400.2 Gy.
"During the procedure, patient was infused with 1.067 Gbq of Y-90. Upon completion of the infusion, based on residual exposure readings, it was determined that an estimated dose of 0.522 Gbq was delivered to the patient, 50% of the written directive. Given the Y-90 supply vial was empty, based on the 0.00 mR/hr reading on the adjacent dosimeter, it has been speculated that Y-90 was held up in the micro-catheter. AU suspects this high residual waste reading was due to a slower infusion of the treatment dose and flushing fluid; this will be determined at a later date when the yttrium-90 waste material has decayed and can be safely broken down with individual components measured. The referring physician (AU), informed the patient of the event.
"RHB will be following up on the medical event."
CA 5010 Number: 070121
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: 55477
Rep Org: COLORADO DEPT OF HEALTH
Licensee: One Renaissance LLC
Region: 4
City: Denver State: CO
County:
License #: GL002564
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Donald Norwood
Licensee: One Renaissance LLC
Region: 4
City: Denver State: CO
County:
License #: GL002564
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Donald Norwood
Notification Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 07/01/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 07/01/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 10/15/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following information was received via email:
"One exit sign, containing 12.57 Ci of tritium, was reported as lost during annual registration. The location of the sign is unknown."
NMED No.: CO210024
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following information was received via email:
"One exit sign, containing 12.57 Ci of tritium, was reported as lost during annual registration. The location of the sign is unknown."
NMED No.: CO210024
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Agreement State
Event Number: 55615
Rep Org: NJ Dept of Environmental Protection
Licensee: Rutgers
Region: 1
City: New Brunswick State: NJ
County:
License #: 460345
Agreement: Y
Docket:
NRC Notified By: Richard Peros
HQ OPS Officer: Karen Cotton-Gross
Licensee: Rutgers
Region: 1
City: New Brunswick State: NJ
County:
License #: 460345
Agreement: Y
Docket:
NRC Notified By: Richard Peros
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 11/29/2021
Notification Time: 16:20 [ET]
Event Date: 07/01/2021
Event Time: 00:00 [EST]
Last Update Date: 11/29/2021
Notification Time: 16:20 [ET]
Event Date: 07/01/2021
Event Time: 00:00 [EST]
Last Update Date: 11/29/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lally, Christopher (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Lally, Christopher (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 12/29/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST NI-63 SOURCE
The following information was received from the state of New Jersey Department of Environmental Protection:
"The Radiation Safety Officer of Rutgers University informed the New Jersey Department of Environmental Protection that one sealed source device, with an installed source, cannot be found and is considered lost. The source in question is a Ni-63, electron capture detector source, serial number U1739, to be used in Agilent HP Gas Chromatograph, Model # HP6890, serial number US10204036 electron capture detection device. The source contained 15 mCi of activity. The device was present during the licensee's April, 2021 inventory. When the current inventory was being conducted, the device could not be found. The licensee stated that the lab where the device was located had a burst pipe in June, 2021. It is believed that the device was mistakenly discarded in July, 2021, as part of the clean-up. Rutgers will forward a written report within 30 days."
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
EN Revision Text: AGREEMENT STATE REPORT - LOST NI-63 SOURCE
The following information was received from the state of New Jersey Department of Environmental Protection:
"The Radiation Safety Officer of Rutgers University informed the New Jersey Department of Environmental Protection that one sealed source device, with an installed source, cannot be found and is considered lost. The source in question is a Ni-63, electron capture detector source, serial number U1739, to be used in Agilent HP Gas Chromatograph, Model # HP6890, serial number US10204036 electron capture detection device. The source contained 15 mCi of activity. The device was present during the licensee's April, 2021 inventory. When the current inventory was being conducted, the device could not be found. The licensee stated that the lab where the device was located had a burst pipe in June, 2021. It is believed that the device was mistakenly discarded in July, 2021, as part of the clean-up. Rutgers will forward a written report within 30 days."
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf