Event Notification Report for July 13, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/12/2021 - 07/13/2021
Agreement State
Event Number: 55374
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: The Regents of the University of California (UCSF)
Region: 4
City: San Francisco State: CA
County:
License #: CA-RML 1725-38
Agreement: Y
Docket:
NRC Notified By: L. Robert Greger
HQ OPS Officer: Ossy Font
Licensee: The Regents of the University of California (UCSF)
Region: 4
City: San Francisco State: CA
County:
License #: CA-RML 1725-38
Agreement: Y
Docket:
NRC Notified By: L. Robert Greger
HQ OPS Officer: Ossy Font
Notification Date: 07/22/2021
Notification Time: 20:11 [ET]
Event Date: 07/13/2021
Event Time: 00:00 [PDT]
Last Update Date: 07/22/2021
Notification Time: 20:11 [ET]
Event Date: 07/13/2021
Event Time: 00:00 [PDT]
Last Update Date: 07/22/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
O'KEEFE, NEIL (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
O'KEEFE, NEIL (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 8/20/2021
EN Revision Text: AGREEMENT STATE REPORT - CONTAMINATED PACKAGE
The following was received from the California Radiologic Health Branch (RHB) via email:
"The licensee reported that on 7/13/2021, they received an externally contaminated package containing two unit doses of F-18 (110 minute T1/2 [half life]). The licensee's receipt survey found the outer surface removable contamination level to be 5,417,497 dpm per 100 sq cm. The inside of the package, including the F-18 vials, were not contaminated. The radiopharmacy courier was informed of the excessive contamination, and the radiopharmacy was contacted. The package radiation levels were acceptable. The package was received from Optimal Tracers (CA-RML 7975). RHB will investigate this matter further, including onsite at Optimal Tracers' facility."
5010 Number: 071921
EN Revision Text: AGREEMENT STATE REPORT - CONTAMINATED PACKAGE
The following was received from the California Radiologic Health Branch (RHB) via email:
"The licensee reported that on 7/13/2021, they received an externally contaminated package containing two unit doses of F-18 (110 minute T1/2 [half life]). The licensee's receipt survey found the outer surface removable contamination level to be 5,417,497 dpm per 100 sq cm. The inside of the package, including the F-18 vials, were not contaminated. The radiopharmacy courier was informed of the excessive contamination, and the radiopharmacy was contacted. The package radiation levels were acceptable. The package was received from Optimal Tracers (CA-RML 7975). RHB will investigate this matter further, including onsite at Optimal Tracers' facility."
5010 Number: 071921
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital
Event Number: 55585
Rep Org: VA San Diego Healthcare System
Licensee: US Department of Veteran Affairs
Region: 3
City: San Diego State: CA
County:
License #: 03-23853-01VA
Agreement: N
Docket:
NRC Notified By: Joseph Bravenec
HQ OPS Officer: Thomas Herrity
Licensee: US Department of Veteran Affairs
Region: 3
City: San Diego State: CA
County:
License #: 03-23853-01VA
Agreement: N
Docket:
NRC Notified By: Joseph Bravenec
HQ OPS Officer: Thomas Herrity
Notification Date: 11/17/2021
Notification Time: 14:47 [ET]
Event Date: 07/13/2021
Event Time: 00:00 [PST]
Last Update Date: 04/25/2023
Notification Time: 14:47 [ET]
Event Date: 07/13/2021
Event Time: 00:00 [PST]
Last Update Date: 04/25/2023
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):
Orth, Steve (R3DO)
Fisher, Jennifer (NMSS DAY)
NMSS_Events_Notification, (EMAIL)
Orth, Steve (R3DO)
Fisher, Jennifer (NMSS DAY)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 4/26/2023
EN Revision Text: MEDICAL EVENT - DOSE ABOVE THE PRESCRIBED DOSE
The following was received from the licensee via email:
"The VA National Health Physics Program is reporting a medical event as defined in 10 CFR 35.3045.
"The medical event occurred at the VA San Diego Healthcare System, San Diego, California. The Department of Veterans Affairs holds NRC license number 03-23853-01VA.
"The medical event occurred on July 13, 2021, and was discovered on November 16, 2021. The medical event involved the administration of approximately 152 millicuries of Iodine-131 sodium iodide to a patient. The patient received close to the activity intended by the authorized user physician. However, there was an error on the written directive form - the activity prescribed by the authorized user physician was mistakenly listed as 2 millicuries. Because the patient received the intended treatment, this medical event is not expected to cause any harm to the patient. The VA National Health Physics program has notified the NRC Project Manager for the VA Master Materials license."
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.
* * * RETRACTION FROM BOB BINGMAN TO THOMAS HERRITY AT 1616 EDT ON 04/25/2023 * * *
The following information was provided by the licensee via email:
"The VA National Health Physics Program is retracting an event that was previously reported as a possible medical event. It was reported to the NRC Operations Center on November 17, 2021, pursuant to 10 CFR 35.3045, NRC Event Number 55585.
"The event occurred at the VA San Diego Healthcare System, San Diego, California. The Department of Veterans Affairs holds NRC license number 03-23853-01VA. The event occurred on July 13, 2021. It was discovered on November 16, 2021. The event involved the administration of approximately 152 millicuries of iodine-131 sodium iodide to a patient. There was an error on a form labelled `written directive' - the activity prescribed by the authorized user physician was mistakenly listed as 2 millicuries. There was a second document: the patient medical order, which met the NRC criteria for a written directive, listed a prescribed dosage of 150 millicuries, was signed by the authorized user, and was used by the authorized user as the written directive.
"The basis for this retraction is, this was determined to be a paperwork error only; therefore, a medical event did not occur. Because the patient received the intended treatment, there was no harm to the patient. The facility has taken corrective actions to prevent a recurrence. The VA National Health Physics program has notified the NRC Project Manager for the VA Master Materials license of our plan to retract the event declaration."
Notified R3DO (Stoedter) and NMSS Events Notification (email).
EN Revision Text: MEDICAL EVENT - DOSE ABOVE THE PRESCRIBED DOSE
The following was received from the licensee via email:
"The VA National Health Physics Program is reporting a medical event as defined in 10 CFR 35.3045.
"The medical event occurred at the VA San Diego Healthcare System, San Diego, California. The Department of Veterans Affairs holds NRC license number 03-23853-01VA.
"The medical event occurred on July 13, 2021, and was discovered on November 16, 2021. The medical event involved the administration of approximately 152 millicuries of Iodine-131 sodium iodide to a patient. The patient received close to the activity intended by the authorized user physician. However, there was an error on the written directive form - the activity prescribed by the authorized user physician was mistakenly listed as 2 millicuries. Because the patient received the intended treatment, this medical event is not expected to cause any harm to the patient. The VA National Health Physics program has notified the NRC Project Manager for the VA Master Materials license."
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.
* * * RETRACTION FROM BOB BINGMAN TO THOMAS HERRITY AT 1616 EDT ON 04/25/2023 * * *
The following information was provided by the licensee via email:
"The VA National Health Physics Program is retracting an event that was previously reported as a possible medical event. It was reported to the NRC Operations Center on November 17, 2021, pursuant to 10 CFR 35.3045, NRC Event Number 55585.
"The event occurred at the VA San Diego Healthcare System, San Diego, California. The Department of Veterans Affairs holds NRC license number 03-23853-01VA. The event occurred on July 13, 2021. It was discovered on November 16, 2021. The event involved the administration of approximately 152 millicuries of iodine-131 sodium iodide to a patient. There was an error on a form labelled `written directive' - the activity prescribed by the authorized user physician was mistakenly listed as 2 millicuries. There was a second document: the patient medical order, which met the NRC criteria for a written directive, listed a prescribed dosage of 150 millicuries, was signed by the authorized user, and was used by the authorized user as the written directive.
"The basis for this retraction is, this was determined to be a paperwork error only; therefore, a medical event did not occur. Because the patient received the intended treatment, there was no harm to the patient. The facility has taken corrective actions to prevent a recurrence. The VA National Health Physics program has notified the NRC Project Manager for the VA Master Materials license of our plan to retract the event declaration."
Notified R3DO (Stoedter) and NMSS Events Notification (email).
Agreement State
Event Number: 55355
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Valero Refining-Texas LP
Region: 4
City: Corpus Christi State: TX
County:
License #: L 03360
Agreement: Y
Docket:
NRC Notified By: Randall Alex Redd
HQ OPS Officer: Ossy Font
Licensee: Valero Refining-Texas LP
Region: 4
City: Corpus Christi State: TX
County:
License #: L 03360
Agreement: Y
Docket:
NRC Notified By: Randall Alex Redd
HQ OPS Officer: Ossy Font
Notification Date: 07/15/2021
Notification Time: 10:42 [ET]
Event Date: 07/13/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/15/2021
Notification Time: 10:42 [ET]
Event Date: 07/13/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
TAYLOR, NICK (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
TAYLOR, NICK (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 8/13/2021
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER
The following was received from the Texas Department of State Health Services via email:
"On July 13, 2021, the licensee discovered a stuck shutter in the open position during a 6 month shutter test. This is the normal operating position and there is not expected to be any additional dose outside of normal operations to workers or public."
"The device was a Vega SH-F2B density/level gauge (serial number 3578CR), with a 200 mCi CS-137 source (serial number 3578CR)."
Texas incident number: I-9869
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER
The following was received from the Texas Department of State Health Services via email:
"On July 13, 2021, the licensee discovered a stuck shutter in the open position during a 6 month shutter test. This is the normal operating position and there is not expected to be any additional dose outside of normal operations to workers or public."
"The device was a Vega SH-F2B density/level gauge (serial number 3578CR), with a 200 mCi CS-137 source (serial number 3578CR)."
Texas incident number: I-9869