Event Notification Report for July 14, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/13/2021 - 07/14/2021
Agreement State
Event Number: 55352
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Allied Alloys LP
Region: 4
City: Houston State: TX
County:
License #: G02205
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Joanna Bridge
Licensee: Allied Alloys LP
Region: 4
City: Houston State: TX
County:
License #: G02205
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Joanna Bridge
Notification Date: 07/14/2021
Notification Time: 13:50 [ET]
Event Date: 07/14/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/14/2021
Notification Time: 13:50 [ET]
Event Date: 07/14/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/14/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
TAYLOR, NICK (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
CNSNS (MEXICO), - (FAX)
TAYLOR, NICK (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
CNSNS (MEXICO), - (FAX)
EN Revision Imported Date: 8/13/2021
EN Revision Text: AGREEMENT STATE REPORT - MISSING DEVICE
The following was received from the Texas Department of State Health Services [the Agency] via e-mail:
"On July 14, 2021, the licensee notified the Agency that in the process of terminating their license for radioactive materials, the Agency discovered that its records indicated the licensee had at one time a Thermo Niton XL3p-800 device, containing 30 millicuries of americium- 241, which was not on the licensee's current inventory of devices and they learned it had not been on their inventory for years. The licensee stated to the best of their knowledge the analyzer was loaned to a former associated company several years ago and this company was then sold or dissolved. It appears the analyzer was not returned to the licensee. The individuals who were, or may have been involved, are no longer employed by the licensee so further information is not available at this time. An investigation is ongoing. More information will be provided as it is obtained in accordance with SA-300.
"Texas Incident No.: I-9868"
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 - MISSING DEVICE
The following was received from the Texas Department of State Health Services [the Agency] via e-mail:
"On July 14, 2021, the licensee notified the Agency that in the process of terminating their license for radioactive materials, the Agency discovered that its records indicated the licensee had at one time a Thermo Niton XL3p-800 device, containing 30 millicuries of americium- 241, which was not on the licensee's current inventory of devices and they learned it had not been on their inventory for years. The licensee stated to the best of their knowledge the analyzer was loaned to a former associated company several years ago and this company was then sold or dissolved. It appears the analyzer was not returned to the licensee. The individuals who were, or may have been involved, are no longer employed by the licensee so further information is not available at this time. An investigation is ongoing. More information will be provided as it is obtained in accordance with SA-300.
"Texas Incident No.: I-9868"
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
Hospital
Event Number: 55353
Rep Org: Richard L. Roudebush VA Med Center
Licensee: US Department of Veteran Affairs
Region: 3
City: Indianapolis State: IN
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: Katherine Boyd
HQ OPS Officer: Jeffrey Whited
Licensee: US Department of Veteran Affairs
Region: 3
City: Indianapolis State: IN
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: Katherine Boyd
HQ OPS Officer: Jeffrey Whited
Notification Date: 07/14/2021
Notification Time: 16:03 [ET]
Event Date: 07/14/2021
Event Time: 10:45 [EDT]
Last Update Date: 07/14/2021
Notification Time: 16:03 [ET]
Event Date: 07/14/2021
Event Time: 10:45 [EDT]
Last Update Date: 07/14/2021
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):
KOZAK, LAURA (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
KOZAK, LAURA (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 8/13/2021
EN Revision Text: MEDICAL EVENT - UNDER DOSE
The following was received from the licensee via email:
"Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, which holds Permit Number 13-00694-03 under the VA master materials license, reported discovery of a medical event to NHPP [VA National Health Physics Program] at approximately 1045 EDT, July 14, 2021. A Y-90 microsphere therapy administration for liver cancer was performed on July 14, 2021. The dosage was intended for two segments of the left lobe of the liver. Post implant surveys of the administration set found an elevated amount of Y-90 present. Measurements and calculations indicated the patient had received about 63 percent of the prescribed activity. The patient has been notified. There is no expectation at this time of harm to the patient.
"NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045. NHPP has notified our NRC Region III Project Manager, Bryan Parker."
This event is reportable pursuant to 10 CFR 35.3045.
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: MEDICAL EVENT - UNDER DOSE
The following was received from the licensee via email:
"Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, which holds Permit Number 13-00694-03 under the VA master materials license, reported discovery of a medical event to NHPP [VA National Health Physics Program] at approximately 1045 EDT, July 14, 2021. A Y-90 microsphere therapy administration for liver cancer was performed on July 14, 2021. The dosage was intended for two segments of the left lobe of the liver. Post implant surveys of the administration set found an elevated amount of Y-90 present. Measurements and calculations indicated the patient had received about 63 percent of the prescribed activity. The patient has been notified. There is no expectation at this time of harm to the patient.
"NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045. NHPP has notified our NRC Region III Project Manager, Bryan Parker."
This event is reportable pursuant to 10 CFR 35.3045.
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: 55354
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: Genesis Hospital
Region: 3
City: Zanesville State: OH
County:
License #: 02120610006
Agreement: Y
Docket:
NRC Notified By: Michael J Rubadue
HQ OPS Officer: Ossy Font
Licensee: Genesis Hospital
Region: 3
City: Zanesville State: OH
County:
License #: 02120610006
Agreement: Y
Docket:
NRC Notified By: Michael J Rubadue
HQ OPS Officer: Ossy Font
Notification Date: 07/15/2021
Notification Time: 10:11 [ET]
Event Date: 07/14/2021
Event Time: 00:00 [EDT]
Last Update Date: 07/15/2021
Notification Time: 10:11 [ET]
Event Date: 07/14/2021
Event Time: 00:00 [EDT]
Last Update Date: 07/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
KOZAK, LAURA (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
KOZAK, LAURA (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
EN Revision Imported Date: 8/13/2021
EN Revision Text: AGREEMENT STATE REPORT - DOSE ADMINISTERED VARIED BY MORE THAN 25 PERCENT
The following was received from the Ohio Department of Health via email:
"A patient whose thyroid had been removed was to receive treatment for the remaining nodules. The WD [(written directive)] prescribed 30 mCi I-131 NaI. However the licensee ordered and administered 100 mCi. The expected whole body dose is 26.64 rem and dose to the bladder wall is 225.7 rad."
Item Number: OH210006
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 - DOSE ADMINISTERED VARIED BY MORE THAN 25 PERCENT
The following was received from the Ohio Department of Health via email:
"A patient whose thyroid had been removed was to receive treatment for the remaining nodules. The WD [(written directive)] prescribed 30 mCi I-131 NaI. However the licensee ordered and administered 100 mCi. The expected whole body dose is 26.64 rem and dose to the bladder wall is 225.7 rad."
Item Number: OH210006
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: 55386
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: Piedmont Fayette Hospital
Region: 1
City: Fayetteville State: GA
County:
License #: GA 1340-1
Agreement: Y
Docket:
NRC Notified By: John Hays
HQ OPS Officer: Howie Crouch
Licensee: Piedmont Fayette Hospital
Region: 1
City: Fayetteville State: GA
County:
License #: GA 1340-1
Agreement: Y
Docket:
NRC Notified By: John Hays
HQ OPS Officer: Howie Crouch
Notification Date: 07/30/2021
Notification Time: 13:47 [ET]
Event Date: 07/14/2021
Event Time: 00:00 [EDT]
Last Update Date: 09/27/2021
Notification Time: 13:47 [ET]
Event Date: 07/14/2021
Event Time: 00:00 [EDT]
Last Update Date: 09/27/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
CAHILL, CHRISTOPHER (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
CAHILL, CHRISTOPHER (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 10/27/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION
The following information was received from NMED for the Georgia Radioactive Materials Program:
"This incident occurred on July 14 at Piedmont Fayette Hospital (GA 1340-1). The unnecessary study was an administration of 25.6 mCi of Tc-99m exametazime-labeled white blood cells (Ceretec WBC), for which the TEDE was about 9 mSv. The individual who received the unnecessary study only came to the hospital for the study and was not an inpatient or there for any other reason."
Georgia Incident Number: 45
* * * UPDATE FROM JOHN HAYS TO THOM HERRITY AT 1142 EDT ON 09/27/21 * * *
The following is a synopsis of the root cause conducted by the Piedmont Fayette Hospital:
The order for the study was received by the imaging center on June 2, 2021. However, the order date for the study was December 16, 2015. The reason for this discrepancy was due to a training mishap at the ordering doctor's office. Staff at the imaging center did not observe the date discrepancy between the fax date at the top of the page and the order date in smaller print elsewhere in the document. The individual receiving the dose had not seen the ordering physician since 2015. At the time the order was received, the individual receiving the dose was under the care of a different physician than the ordering physician and the individual receiving the dose assumed that the different physician had ordered the study.
The hospital Radiation Safety Officer (RSO) has concluded that, because the individual was not actually a patient, the exposure should be reclassified as an exposure to a member of the public, which has lower reporting limits than a misadministration. The TEDE was approximately 8.5 mSv (0.85 rem). No ill effects are anticipated from this exposure. The hospital has initiated re-training for staff to preclude similar confusion going forward.
Notified R1DO (SCHROEDER) and NMSS Events Notification group.
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 MISADMINISTRATION
The following information was received from NMED for the Georgia Radioactive Materials Program:
"This incident occurred on July 14 at Piedmont Fayette Hospital (GA 1340-1). The unnecessary study was an administration of 25.6 mCi of Tc-99m exametazime-labeled white blood cells (Ceretec WBC), for which the TEDE was about 9 mSv. The individual who received the unnecessary study only came to the hospital for the study and was not an inpatient or there for any other reason."
Georgia Incident Number: 45
* * * UPDATE FROM JOHN HAYS TO THOM HERRITY AT 1142 EDT ON 09/27/21 * * *
The following is a synopsis of the root cause conducted by the Piedmont Fayette Hospital:
The order for the study was received by the imaging center on June 2, 2021. However, the order date for the study was December 16, 2015. The reason for this discrepancy was due to a training mishap at the ordering doctor's office. Staff at the imaging center did not observe the date discrepancy between the fax date at the top of the page and the order date in smaller print elsewhere in the document. The individual receiving the dose had not seen the ordering physician since 2015. At the time the order was received, the individual receiving the dose was under the care of a different physician than the ordering physician and the individual receiving the dose assumed that the different physician had ordered the study.
The hospital Radiation Safety Officer (RSO) has concluded that, because the individual was not actually a patient, the exposure should be reclassified as an exposure to a member of the public, which has lower reporting limits than a misadministration. The TEDE was approximately 8.5 mSv (0.85 rem). No ill effects are anticipated from this exposure. The hospital has initiated re-training for staff to preclude similar confusion going forward.
Notified R1DO (SCHROEDER) and NMSS Events Notification group.
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.