Event Notification Report for December 14, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/13/2021 - 12/14/2021
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital
Event Number: 55643
Rep Org: Monument Health
Licensee: Monument Health
Region: 4
City: Rapid City State: SD
County:
License #: 40-00238-04
Agreement: N
Docket:
NRC Notified By: Jim McKee
HQ OPS Officer: Mike Stafford
Licensee: Monument Health
Region: 4
City: Rapid City State: SD
County:
License #: 40-00238-04
Agreement: N
Docket:
NRC Notified By: Jim McKee
HQ OPS Officer: Mike Stafford
Notification Date: 12/14/2021
Notification Time: 15:38 [ET]
Event Date: 12/14/2021
Event Time: 09:00 [MST]
Last Update Date: 01/05/2022
Notification Time: 15:38 [ET]
Event Date: 12/14/2021
Event Time: 09:00 [MST]
Last Update Date: 01/05/2022
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):
Proulx, David (R4)
NMSS_Events_Notification, (EMAIL)
Proulx, David (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 2/4/2022
EN Revision Text: NON-AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following is a summary of a phone call with the licensee:
A patient was implanted with an I-125 seed of 21.45 millicuries for the radiation therapy. The patient was prescribed to receive radiation therapy to 93.17% of their prostate. Post implant dosimetry indicated that the patient only received a dose to 39.10% of the prostate. There were no unintended health affects as a result of this event.
* * * RETRACTION ON 01/05/2022 AT 1854 EST FROM JIM McKEE TO JEFFREY WHITED * * *
The following is a summary of a phone call with the licensee:
Following discussions with an NRC inspector, the licensee determined that the correct activity had been implanted into the correct area. As such, a medical event did not need to be reported and the licensee retracted the event.
Notified R4DO (Roldan-Otero) and NMSS Event Notification.
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 - MEDICAL UNDERDOSE
The following is a summary of a phone call with the licensee:
A patient was implanted with an I-125 seed of 21.45 millicuries for the radiation therapy. The patient was prescribed to receive radiation therapy to 93.17% of their prostate. Post implant dosimetry indicated that the patient only received a dose to 39.10% of the prostate. There were no unintended health affects as a result of this event.
* * * RETRACTION ON 01/05/2022 AT 1854 EST FROM JIM McKEE TO JEFFREY WHITED * * *
The following is a summary of a phone call with the licensee:
Following discussions with an NRC inspector, the licensee determined that the correct activity had been implanted into the correct area. As such, a medical event did not need to be reported and the licensee retracted the event.
Notified R4DO (Roldan-Otero) and NMSS Event Notification.
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: 55645
Rep Org: Alabama Radiation Control
Licensee: Agriculture Veterinary Diagnostic Lab
Region: 1
City: Auburn State: AL
County:
License #: 15
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Brian Lin
Licensee: Agriculture Veterinary Diagnostic Lab
Region: 1
City: Auburn State: AL
County:
License #: 15
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Brian Lin
Notification Date: 12/14/2021
Notification Time: 17:34 [ET]
Event Date: 12/14/2021
Event Time: 00:00 [CST]
Last Update Date: 05/04/2022
Notification Time: 17:34 [ET]
Event Date: 12/14/2021
Event Time: 00:00 [CST]
Last Update Date: 05/04/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Young, Matt (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 5/5/2022
EN Revision Text: AGREEMENT STATE REPORT - UNAUTHORIZED DISPOSAL OF RADIOACTIVE MATERIALS
The following information was received by the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:
"On 12/14/21, the Agency spoke with a representative of Alabama Dept. of Agriculture Veterinary Diagnostic Lab in Auburn, Alabama regarding information in a letter related to disposal of an ECD [electron capture detector]. The representative confirmed that the ECD was incinerated by an unauthorized/unlicensed company. The Agency is continuing to investigate. The Veterinary Diagnostic lab does not have a specific license; the Agency has identified it as GL registration no. 15. The device was manufactured by Varian, with source model 02-001972-00, nominal activity of 15 millicuries of nickel-63."
AL incident no.: 21-35
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
* * * UPDATE ON 5/4/22 FROM CASON COAN TO KARL DIEDERICH VIA E-MAIL * * *
The State closed out this incident on May 4, 2022. The source, originally 15 mCi on 10/1999, is ascertained to have been incinerated by MedSharp Disposal on 12/6/2021. Remnants of incineration were transported to a Waste Management class 1 landfill in Campbelton, Florida. Chase Environmental Group was contracted to survey and characterize contamination of the incinerator. Contamination attributable to niclel-63 was found inside the incinerator, estimated activity 6 to 13 microcuries. It is believed that the majority, if not all remaining, of source activity is in the landfill. Chase Environmental reported that remaining material would not result in an average member of the critical group receiving over 0.016 mrem/year, and that it is highly unlikely that a member of the public would receive over 10 mrem/year from nickel-63 present in air emissions. The incinerator was free-released for use. The Alabama Office of Radiation Control issued a violation of severity category IV to Veterinary Diagnostic Lab.
NMED item number 210541.
Notified R1DO (Lally) and NMSS_Events_Notification and ILTAB via e-mail.
EN Revision Text: AGREEMENT STATE REPORT - UNAUTHORIZED DISPOSAL OF RADIOACTIVE MATERIALS
The following information was received by the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:
"On 12/14/21, the Agency spoke with a representative of Alabama Dept. of Agriculture Veterinary Diagnostic Lab in Auburn, Alabama regarding information in a letter related to disposal of an ECD [electron capture detector]. The representative confirmed that the ECD was incinerated by an unauthorized/unlicensed company. The Agency is continuing to investigate. The Veterinary Diagnostic lab does not have a specific license; the Agency has identified it as GL registration no. 15. The device was manufactured by Varian, with source model 02-001972-00, nominal activity of 15 millicuries of nickel-63."
AL incident no.: 21-35
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
* * * UPDATE ON 5/4/22 FROM CASON COAN TO KARL DIEDERICH VIA E-MAIL * * *
The State closed out this incident on May 4, 2022. The source, originally 15 mCi on 10/1999, is ascertained to have been incinerated by MedSharp Disposal on 12/6/2021. Remnants of incineration were transported to a Waste Management class 1 landfill in Campbelton, Florida. Chase Environmental Group was contracted to survey and characterize contamination of the incinerator. Contamination attributable to niclel-63 was found inside the incinerator, estimated activity 6 to 13 microcuries. It is believed that the majority, if not all remaining, of source activity is in the landfill. Chase Environmental reported that remaining material would not result in an average member of the critical group receiving over 0.016 mrem/year, and that it is highly unlikely that a member of the public would receive over 10 mrem/year from nickel-63 present in air emissions. The incinerator was free-released for use. The Alabama Office of Radiation Control issued a violation of severity category IV to Veterinary Diagnostic Lab.
NMED item number 210541.
Notified R1DO (Lally) and NMSS_Events_Notification and ILTAB via e-mail.
Agreement State
Event Number: 55647
Rep Org: Tennessee Div of Rad Health
Licensee: ECS Southeast
Region: 1
City: Mt. Juliet State: TN
County:
License #: R-94042-A26
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Mike Stafford
Licensee: ECS Southeast
Region: 1
City: Mt. Juliet State: TN
County:
License #: R-94042-A26
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Mike Stafford
Notification Date: 12/15/2021
Notification Time: 14:08 [ET]
Event Date: 12/14/2021
Event Time: 11:00 [EST]
Last Update Date: 12/15/2021
Notification Time: 14:08 [ET]
Event Date: 12/14/2021
Event Time: 11:00 [EST]
Last Update Date: 12/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1)
NMSS_Events_Notification, (EMAIL)
Young, Matt (R1)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 1/14/2022
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following was received from the Tennessee Division of Radiological Health via email:
"A Troxler model 3440 (SN 21556) was run over by a dump truck at a local construction site. Source is in the shielded position within the unit. Gauge is cordoned off from staff. However, the gauge is not operational.
"Corrective actions will be updated with a report within 30 days."
The gauge contains a 40 mCi Am:Be-241 and a 8 mCi Cs-137 source.
State Event Report ID Number: TN-21-116
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following was received from the Tennessee Division of Radiological Health via email:
"A Troxler model 3440 (SN 21556) was run over by a dump truck at a local construction site. Source is in the shielded position within the unit. Gauge is cordoned off from staff. However, the gauge is not operational.
"Corrective actions will be updated with a report within 30 days."
The gauge contains a 40 mCi Am:Be-241 and a 8 mCi Cs-137 source.
State Event Report ID Number: TN-21-116
Agreement State
Event Number: 55650
Rep Org: Tennessee Div of Rad Health
Licensee: Methodist Le Bonheur Healthcare
Region: 1
City: Memphis State: TN
County:
License #: R-79027-H26
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Mike Stafford
Licensee: Methodist Le Bonheur Healthcare
Region: 1
City: Memphis State: TN
County:
License #: R-79027-H26
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Mike Stafford
Notification Date: 12/15/2021
Notification Time: 15:48 [ET]
Event Date: 12/14/2021
Event Time: 00:00 [EST]
Last Update Date: 12/15/2021
Notification Time: 15:48 [ET]
Event Date: 12/14/2021
Event Time: 00:00 [EST]
Last Update Date: 12/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Young, Matt (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 1/14/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following was received from the Tennessee Division of Radiological Health via email:
"During the removal of I-125 seeds from a patient, only 22 of 23 seeds were recovered. No survey readings above background were discovered in the operating room. It was concluded that the seed was not present in the patient upon operating room entry. Exam rooms visited by the patient were checked and showed no readings above background levels. The seed is thought to have been lost during implant with surgical drape on 12/7/21. The seed information is as follows:
"Manufacturer: BEST
"Model: 2301
"Isotope: I-125
"Activity: 1.6 mCi
"Corrective actions will be updated with a report within 30 days."
State Event Report ID Number: TN-21-117
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 BRACHYTHERAPY SEED
The following was received from the Tennessee Division of Radiological Health via email:
"During the removal of I-125 seeds from a patient, only 22 of 23 seeds were recovered. No survey readings above background were discovered in the operating room. It was concluded that the seed was not present in the patient upon operating room entry. Exam rooms visited by the patient were checked and showed no readings above background levels. The seed is thought to have been lost during implant with surgical drape on 12/7/21. The seed information is as follows:
"Manufacturer: BEST
"Model: 2301
"Isotope: I-125
"Activity: 1.6 mCi
"Corrective actions will be updated with a report within 30 days."
State Event Report ID Number: TN-21-117
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