Event Notification Report for September 28, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/27/2021 - 09/28/2021
Agreement State
Event Number: 55499
Rep Org: NEVADA RADIOLOGICAL HEALTH
Licensee: GenesisCare USA, LLC
Region: 4
City: Las Vegas State: NV
County:
License #: 03-12-13639-01
Agreement: Y
Docket:
NRC Notified By: John Follette
HQ OPS Officer: Kerby Scales
Licensee: GenesisCare USA, LLC
Region: 4
City: Las Vegas State: NV
County:
License #: 03-12-13639-01
Agreement: Y
Docket:
NRC Notified By: John Follette
HQ OPS Officer: Kerby Scales
Notification Date: 09/29/2021
Notification Time: 18:41 [ET]
Event Date: 09/28/2021
Event Time: 00:00 [PDT]
Last Update Date: 09/29/2021
Notification Time: 18:41 [ET]
Event Date: 09/28/2021
Event Time: 00:00 [PDT]
Last Update Date: 09/29/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PROULX, DAVID (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
PROULX, DAVID (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 10/29/2021
EN Revision Text: AGREEMENT STATE REPORT - DOSE ADMINISTERED WRONG PATIENT
The following is a summary of a report received from the state of Nevada via telephone and email:
During an inspection on 9/28/21 at Genesis Care, the State discovered that a patient incorrectly received radiation treatment for breast cancer in 2001. Pathology results were accidentally switched resulting in the wrong patient receiving treatment. A patient was treated with a mamosite breast applicator that didn't have breast cancer. The dose received by the patient is unknown at this time. The patient with breast cancer was not treated. The State is following up with the licensee and will provide updated information.
Nevada Item Number: NV210017
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 WRONG PATIENT
The following is a summary of a report received from the state of Nevada via telephone and email:
During an inspection on 9/28/21 at Genesis Care, the State discovered that a patient incorrectly received radiation treatment for breast cancer in 2001. Pathology results were accidentally switched resulting in the wrong patient receiving treatment. A patient was treated with a mamosite breast applicator that didn't have breast cancer. The dose received by the patient is unknown at this time. The patient with breast cancer was not treated. The State is following up with the licensee and will provide updated information.
Nevada Item Number: NV210017
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: 55496
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: Jacksonville Cardiovascular Center, P.L.
Region: 1
City: Jacksonville State: FL
County:
License #: 3725-2
Agreement: Y
Docket:
NRC Notified By: Paul Norman
HQ OPS Officer: Kerby Scales
Licensee: Jacksonville Cardiovascular Center, P.L.
Region: 1
City: Jacksonville State: FL
County:
License #: 3725-2
Agreement: Y
Docket:
NRC Notified By: Paul Norman
HQ OPS Officer: Kerby Scales
Notification Date: 09/28/2021
Notification Time: 13:45 [ET]
Event Date: 09/28/2021
Event Time: 00:00 [EDT]
Last Update Date: 09/28/2021
Notification Time: 13:45 [ET]
Event Date: 09/28/2021
Event Time: 00:00 [EDT]
Last Update Date: 09/28/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
SCHROEDER, DAN (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
SCHROEDER, DAN (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 10/28/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCE
The following is summary of an event received from the state of Florida via email:
A Cs-137 source (184.3 microcuries) was discovered missing at the Reception and Medical Center (RMC) of the Lake Butler Nuclear Medicine Department, at the Lake Butler Department of Corrections (DOC). The medical center is contracted to operate under Jacksonville Cardiovascular Center. The building is a modular trailer. The missing source was noted during a scheduled inventory. The source is believed to have been moved or relocated by the DOC during construction to repair a collapsed floor. The source is believed to be somewhere in the trailer.
Florida Incident Number: FL21-122
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 SOURCE
The following is summary of an event received from the state of Florida via email:
A Cs-137 source (184.3 microcuries) was discovered missing at the Reception and Medical Center (RMC) of the Lake Butler Nuclear Medicine Department, at the Lake Butler Department of Corrections (DOC). The medical center is contracted to operate under Jacksonville Cardiovascular Center. The building is a modular trailer. The missing source was noted during a scheduled inventory. The source is believed to have been moved or relocated by the DOC during construction to repair a collapsed floor. The source is believed to be somewhere in the trailer.
Florida Incident Number: FL21-122
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