Event Notification Report for November 16, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/15/2021 - 11/16/2021
Hospital
Event Number: 55587
Rep Org: Community Health Network
Licensee: Community Health Network
Region: 3
City: Indianapolis State: IN
County:
License #: 13-06009-01
Agreement: N
Docket:
NRC Notified By: Erin Bell
HQ OPS Officer: Thomas Herrity
Licensee: Community Health Network
Region: 3
City: Indianapolis State: IN
County:
License #: 13-06009-01
Agreement: N
Docket:
NRC Notified By: Erin Bell
HQ OPS Officer: Thomas Herrity
Notification Date: 11/17/2021
Notification Time: 16:53 [ET]
Event Date: 11/16/2021
Event Time: 11:00 [EST]
Last Update Date: 11/17/2021
Notification Time: 16:53 [ET]
Event Date: 11/16/2021
Event Time: 11:00 [EST]
Last Update Date: 11/17/2021
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):
Orth, Steve (R3)
NMSS_Events_Notification, (EMAIL)
Orth, Steve (R3)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/17/2021
EN Revision Text: NON-AGREEMENT STATE REPORT - UNDER DOSE
The following is a synopsis of a report from the licensee:
On November 16, 2021 at approximately 1100 (EST) while delivering a Y-90 Thermosphere treatment to the liver, the vial septum failed under pressure. This resulted in not all the dose being delivered to the patient. The prescribed dose was 35.1 millicuries. The delivered dose was 14.4 millicuries. All the delivered dose was to the correct organ. No deleterious effects to the patient are expected.
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: NON-AGREEMENT STATE REPORT - UNDER DOSE
The following is a synopsis of a report from the licensee:
On November 16, 2021 at approximately 1100 (EST) while delivering a Y-90 Thermosphere treatment to the liver, the vial septum failed under pressure. This resulted in not all the dose being delivered to the patient. The prescribed dose was 35.1 millicuries. The delivered dose was 14.4 millicuries. All the delivered dose was to the correct organ. No deleterious effects to the patient are expected.
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: 55588
Rep Org: Wisconsin Radiation Protection
Licensee: Froedtert South, Inc.
Region: 3
City: Pleasant Prairie State: WI
County:
License #: 059-1319-01
Agreement: Y
Docket:
NRC Notified By: Luther S. Loehrke
HQ OPS Officer: Mike Stafford
Licensee: Froedtert South, Inc.
Region: 3
City: Pleasant Prairie State: WI
County:
License #: 059-1319-01
Agreement: Y
Docket:
NRC Notified By: Luther S. Loehrke
HQ OPS Officer: Mike Stafford
Notification Date: 11/17/2021
Notification Time: 17:23 [ET]
Event Date: 11/16/2021
Event Time: 00:00 [CST]
Last Update Date: 11/17/2021
Notification Time: 17:23 [ET]
Event Date: 11/16/2021
Event Time: 00:00 [CST]
Last Update Date: 11/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Orth, Steve (R3)
NMSS_Events_Notification, (EMAIL)
Orth, Steve (R3)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/17/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL OVERDOSAGE
The following was received from the Wisconsin Radiation Protection Section (the State):
"On November 17, 2021, the licensee reported to the State a medical event involving Y-90 SIR-Spheres that was discovered that same day and occurred on November 16, 2021. Two administrations were prescribed to different segments of the left lobe of the liver, one of 0.4 GBq and one of 1.6 GBq. A calculation error occurred while converting these doses from GBq to milli-Ci which resulted in administered doses of 0.51 GBq and 2.3 GBq respectively; both of which are 27 percent above prescription. The State will continue to follow-up on the event."
No deleterious effects to the patient are expected. All dose was delivered to the intended organ.
Wisconsin Event Report ID Number: WI210008
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 OVERDOSAGE
The following was received from the Wisconsin Radiation Protection Section (the State):
"On November 17, 2021, the licensee reported to the State a medical event involving Y-90 SIR-Spheres that was discovered that same day and occurred on November 16, 2021. Two administrations were prescribed to different segments of the left lobe of the liver, one of 0.4 GBq and one of 1.6 GBq. A calculation error occurred while converting these doses from GBq to milli-Ci which resulted in administered doses of 0.51 GBq and 2.3 GBq respectively; both of which are 27 percent above prescription. The State will continue to follow-up on the event."
No deleterious effects to the patient are expected. All dose was delivered to the intended organ.
Wisconsin Event Report ID Number: WI210008
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: 55637
Rep Org: Louisiana DEQ
Licensee: Halliburton
Region: 4
City: Broussard State: LA
County: Plaqeumines
License #: LA-2353-L01, Amendment 83
Agreement: Y
Docket:
NRC Notified By: James M. Pate III
HQ OPS Officer: Karen Cotton-Gross
Licensee: Halliburton
Region: 4
City: Broussard State: LA
County: Plaqeumines
License #: LA-2353-L01, Amendment 83
Agreement: Y
Docket:
NRC Notified By: James M. Pate III
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 12/09/2021
Notification Time: 10:27 [ET]
Event Date: 11/16/2021
Event Time: 00:00 [CST]
Last Update Date: 12/09/2021
Notification Time: 10:27 [ET]
Event Date: 11/16/2021
Event Time: 00:00 [CST]
Last Update Date: 12/09/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Cale (R4)
NMSS_Events_Notification, (EMAIL)
Lizette Roldan-Otero (R4)
Young, Cale (R4)
NMSS_Events_Notification, (EMAIL)
Lizette Roldan-Otero (R4)
EN Revision Imported Date: 1/7/2022
EN Revision Text: AGREEMENT STATE REPORT - NOTIFICATION OF ABANDONMENT OF WELL LOGGING SOURCES
This information was provided by via email from LA Department of Environmental Quality (LDEQ):
"On December 8, 2021, LDEQ was notified by Halliburton Energy Services, Inc., Senior Radiation Safety Officer via email concerning well logging sources that were abandoned downhole. According to the RSO, the two sources were one 555 GBq (15 Ci) Eckert and Ziegler Model LWD4173, source s/n EZ16008 and one 74 GBq (2.0 Ci) QSA Global, Model CDC.CY13, source s/n 54903B. Halliburton was performing directional drilling for Whitney Oil & Gas LLC. The well was in inland waters. The date of occurrence was November 16, 2021. Well Name and Registration: Well No. 138 and 17721205480000."
Event Report ID No.: LA 202100011
EN Revision Text: AGREEMENT STATE REPORT - NOTIFICATION OF ABANDONMENT OF WELL LOGGING SOURCES
This information was provided by via email from LA Department of Environmental Quality (LDEQ):
"On December 8, 2021, LDEQ was notified by Halliburton Energy Services, Inc., Senior Radiation Safety Officer via email concerning well logging sources that were abandoned downhole. According to the RSO, the two sources were one 555 GBq (15 Ci) Eckert and Ziegler Model LWD4173, source s/n EZ16008 and one 74 GBq (2.0 Ci) QSA Global, Model CDC.CY13, source s/n 54903B. Halliburton was performing directional drilling for Whitney Oil & Gas LLC. The well was in inland waters. The date of occurrence was November 16, 2021. Well Name and Registration: Well No. 138 and 17721205480000."
Event Report ID No.: LA 202100011