Event Notification Report for August 09, 2021

EN Revision Imported Date: 8/9/2021

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

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: 8/9/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received from the Kentucky Department of Radiation Control, Radiation Health Branch (RHB) via email:

"At approximately 1230 CDT on 7/29/21 the Hospital [Radiation Safety Officer] RSO called RHB to report a failure of a Therasphere Y-90 administration kit. Authorized User (AU) indicated an almost immediate failure to administer the dose. There was no flow into the administration catheter. Saline observed exiting the administration set up into an overflow vial. After adjusting the pressure and a second attempt failed, a call was placed to the administration kit representative. Three more attempts failed. The AU decided to stop the process and remove the administration catheter. Patient procedure was stopped. Not rescheduled at this time. A survey of the vial and administration set up, and multiple patient surveys seem to indicate that no dose was administered to the patient.

"Y-90 set up and vials were packaged and stored into appropriate waste. No contamination, no release of material. No patient administration. Expected 4.15 GBq and received none. Licensee suspects an administration set up kit failure. Licensee will provide full reports to the RHB staff within 15 days."

KY Event Report ID: 210002

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: 8/9/2021

EN Revision Text: DAMAGED INSTROTEK MOISTURE DENSITY GAUGE

The following is a summary of a phone call with the licensee:

On 7/30/2021 while at the jobsite in Moca, Puerto Rico, the licensee's InstroTek MC-3 Elite gauge was run over by a paving roller while in the safety drum. The gauge plastic casing was damaged and the source rod was broken. The sources were in the shielded position at the time of the incident. The InstroTek gauge serial number is 31331 and contains nominally 10 mCi of Cs-137 and 50 mCi of AmBe.

The damaged gauge was placed in its storage container and returned to the licensee's Cabo Rojo facility for a swipe test. After the incident, the gauge read 0.2 to 0.3 mR/hr at 1 meter with a survey meter.

No overexposures were reported.


* * * RETRACTION ON 8/3/21 AT 1320 EDT FROM ALFONSO BOSQUE TO KERBY SCALES * * *

The following retraction is a summary of a phone call with the licensee:

The Radiation Safety Officer inspected the gauge and verified that the gauge maintained its safety function. The source was secured and a leak test verified no leakage.

Notified R1DO (Eve) and NMSS Event Notification via email.

EN Revision Imported Date: 8/9/2021

EN Revision Text: AGEEMENT STATE REPORT - MEDICAL EVENT

The following was received from the Minnesota Department of Health via email:

"The Mayo Clinic Rochester, MN had a medical event in which the total dose differs from the prescribed dose by greater than 20 percent and the dose difference to the whole body exceeds 5 rem. Under clinical trials on 7/29/2021, a patient who was prescribed 11.2 mCi of I-131 as an infusion of IOMAB-B Therapy, only received 5.74 mCi. The licensee reports an issue with air in the tubing that prevented the entire administration of the treatment. They are continuing to investigate and will submit a final report within 15 days."

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: 8/9/2021

EN Revision Text: AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

The following information was received from the state of Nevada via email:

"Authorized user brought a portable nuclear gauge (PNG) up to Reno, Nevada (their license is based out of Las Vegas) to use on job today, August 2, 2021, and stayed the night of August 1, 2021, at the Atlantis, parked in the South East Corner lot. When he went out at 0800 PDT he noticed that the gauge was missing and the chains had been cut. He reported the missing gauge to the [Radiation Safety Officer] RSO and looked around the parking lot, drove the perimeter of the lot and a few blocks around the hotel and did not find the gauge. They notified Reno PD of the stolen gauge and [was notified they] would respond by 0915 PDT (no report number available yet). Atlantis is checking their parking lot security cameras to see if they caught anything on the camera to get a line on the device and fix the time line."

Nevada NMED report number: NV210010

* * * UPDATE FROM COREY CREVELING TO HOWIE CROUCH AT 1923 EDT ON 8/2/21 * * *
The following update was received via email:

"The PNG is from Terracon Consultants, Inc. Sacramento, California office covered by California RML CA 8064-34, and it entered the State of Nevada without reciprocity authorization or shipping papers of any kind. Updated the reciprocity pull down and the license number. Added the police report number [21-13940]. Atlantis Hotel-Casino will provide anything found in their search of security camera footage to Reno Police Department.

Notified R4DO (Gepford) and NMSS and ILTAB via email.

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 Imported Date: 8/9/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL UNDERDOSE EXCEEDING 20 PERCENT

The following information was obtained from the Illinois Emergency Management Agency (the Agency) via email:

"Children's Hospital of Chicago Medical Center (IL-01165-01), contacted the Agency on 8/2/21 to advise that a pediatric administration of Y-90 resulted in an underdose exceeding 20%. The incident occurred today, August 2, 2021. No untoward medical impact was expected to the patient.

"The licensee's radiation safety officer designee contacted [the Agency] to advise that a pediatric patient scheduled to receive Y-90 microsphere therapy (Theraspheres) for hepatocellular cancer on August 2, 2021 received only 75 percent of the dose prescribed in the written directive. A Therasphere representative was on site for the administration and did not note stasis. The licensee suspects a kink in the delivery catheter but is currently imaging the RAM waste and tubing to confirm. No personnel or area contamination was reported. It remains to be determined if the dose delivered was clinically effective or if an additional treatment is planned. The patient's father was advised. It is unclear at this point if the referring physician has been notified. Agency inspectors will perform a reactionary inspection tomorrow, August 3, 2021, to assist in determining root cause and gather the additional information required. This matter is reportable under 32 Ill. Adm. Code 335.1080(a)(1)(B). A written report will be required of the licensee within 15 days."

Illinois NMED report number: IL210022

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: 8/9/2021

EN Revision Text: NON-LICENSED SUPERVISORY PERSONNEL VIOLATED FFD POLICY

A non-licensed supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified.

EN Revision Imported Date: 8/9/2021

EN Revision Text: REACTOR WATER OUT OF TECHNICAL SPECIFICATION

"On Thursday, August 5, 2021, during a routine University of Utah Training Reactor (UUTR) operation, an 'out of Technical Specification' indicator reading by water quality sensors for pH and conductivity occurred following shutdown. No other issues were noted, and the reactor and facility are secure.

"Description of Event: At the end of the reactor run, UUTR operators recorded sensor pH as 5.15, pre-demineralizer conductivity was 6.444 micro-mhos/cm, and post-demineralizer conductivity was 0.054 micro-mhos/cm. UUTR Technical Specifications state that the Limiting Condition of Operation (LCO) for pH must fall between 5.5 and 7.5, with a conductivity less than 5.000 micro-mhos/cm. During the start-up procedure, the pH was recorded as 5.6, and pre-demineralizer conductivity was 4.247 micro-mhos/cm, with post-demineralizer conductivity of 0.054 micro-mhos/cm, within UUTR Technical Specifications. It was noted that pH was lower than normal, and conductivity was higher than normal, and this was attributed to the addition of algaecide water treatment actions approximately 10 days prior to the reactor pool, as prolonged maintenance outages led to a need to treat pool water to mitigate algae.

"Response to this Event: Following reactor shutdown on August 5, 2021, the reactor pool clean-up loop was circulated overnight, Thursday to Friday, August 6th 2021, to enable water quality parameters to return to normal acceptable levels.

"Follow-up Actions: UUTR reactor personnel will be inspecting the pool tank on Monday, August 9, 2021, using underwater camera equipment for out of ordinary tank degradation (none is currently apparent). They will also use an external pool cleanup pump to remove any noticeable debris from the bottom of the pool tank, a process last performed June 2020. It is expected that longer run times of the pool circuit cleanup pump and cleaning actions will enable water quality parameters to return to normal operating ranges."