Event Notification Report for November 23, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/22/2021 - 11/23/2021
Agreement State
Event Number: 55608
Rep Org: Texas Dept of State Health Services
Licensee: MEMORIAL HERMANN HEALTH SYSTEM
Region: 4
City: HOUSTON State: TX
County:
License #: L00650
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Lloyd Desotell
Licensee: MEMORIAL HERMANN HEALTH SYSTEM
Region: 4
City: HOUSTON State: TX
County:
License #: L00650
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Lloyd Desotell
Notification Date: 11/24/2021
Notification Time: 14:41 [ET]
Event Date: 11/23/2021
Event Time: 00:00 [CST]
Last Update Date: 11/24/2021
Notification Time: 14:41 [ET]
Event Date: 11/23/2021
Event Time: 00:00 [CST]
Last Update Date: 11/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/23/2021
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE OF PATIENT MEDICAL EVENT
The following was received from the state of Texas (the Agency) via email:
"On November 24, 2021, the licensee notified the Agency that a medical event had occurred at its facility on November 23, 2021. A patient was being treated with SIRTEX SIR-spheres yttrium-90 microspheres. The order for the treatment was 8.1 millicuries.
Following the procedure, it was determined the patient had only received 6.3 millicuries. The licensee reported this was not the result of stasis and is investigating to determine the cause. The licensee has contacted the manufacturer. The Authorized User stated the dose delivered should be high enough for an effective treatment. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident Number: 9896
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 - UNDERDOSE OF PATIENT MEDICAL EVENT
The following was received from the state of Texas (the Agency) via email:
"On November 24, 2021, the licensee notified the Agency that a medical event had occurred at its facility on November 23, 2021. A patient was being treated with SIRTEX SIR-spheres yttrium-90 microspheres. The order for the treatment was 8.1 millicuries.
Following the procedure, it was determined the patient had only received 6.3 millicuries. The licensee reported this was not the result of stasis and is investigating to determine the cause. The licensee has contacted the manufacturer. The Authorized User stated the dose delivered should be high enough for an effective treatment. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident Number: 9896
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.
Non-Agreement State
Event Number: 55653
Rep Org: Lester E. Cox Medical Center
Licensee: Lester E. Cox Medical Center
Region: 3
City: Springfield State: MO
County:
License #: 24-01143-06
Agreement: N
Docket:
NRC Notified By: Kimberly Prescott
HQ OPS Officer: Mike Stafford
Licensee: Lester E. Cox Medical Center
Region: 3
City: Springfield State: MO
County:
License #: 24-01143-06
Agreement: N
Docket:
NRC Notified By: Kimberly Prescott
HQ OPS Officer: Mike Stafford
Notification Date: 12/16/2021
Notification Time: 13:04 [ET]
Event Date: 11/23/2021
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Notification Time: 13:04 [ET]
Event Date: 11/23/2021
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
Person (Organization):
Skokowski, Richard (R3)
ILTAB, (EMAIL)
NMSS_Events_Notification, (EMAIL)
Skokowski, Richard (R3)
ILTAB, (EMAIL)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 1/14/2022
EN Revision Text: NON-AGREEMENT STATE - LOST Co-57 MARKER SOURCE
The following is a summary of a phone call with Lester E. Cox Medical Center:
On November 23, 2021, the licensee was performing a radiography procedure on a patient's lymph node. The procedure involved the use of a Co-57 marker rod source, approximately 13.1 microCi. During the procedure the shielding cap was removed, reference mark was made, the cap was replaced, and the rod was placed back onto a medical cart. At some point following the procedure the licensee recognized that the source was missing. A search of the lab, linen area, and trash was conducted and did not identify the missing source.
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: NON-AGREEMENT STATE - LOST Co-57 MARKER SOURCE
The following is a summary of a phone call with Lester E. Cox Medical Center:
On November 23, 2021, the licensee was performing a radiography procedure on a patient's lymph node. The procedure involved the use of a Co-57 marker rod source, approximately 13.1 microCi. During the procedure the shielding cap was removed, reference mark was made, the cap was replaced, and the rod was placed back onto a medical cart. At some point following the procedure the licensee recognized that the source was missing. A search of the lab, linen area, and trash was conducted and did not identify the missing source.
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