Event Notification Report for December 23, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/22/2021 - 12/23/2021
Agreement State
Event Number: 55677
Rep Org: WA Office of Radiation Protection
Licensee: University of Washington
Region: 4
City: Seattle State: WA
County:
License #: WN-C001-1
Agreement: Y
Docket:
NRC Notified By: James Killingbeck
HQ OPS Officer: Kerby Scales
Licensee: University of Washington
Region: 4
City: Seattle State: WA
County:
License #: WN-C001-1
Agreement: Y
Docket:
NRC Notified By: James Killingbeck
HQ OPS Officer: Kerby Scales
Notification Date: 12/27/2021
Notification Time: 19:43 [ET]
Event Date: 12/23/2021
Event Time: 00:00 [PST]
Last Update Date: 12/27/2021
Notification Time: 19:43 [ET]
Event Date: 12/23/2021
Event Time: 00:00 [PST]
Last Update Date: 12/27/2021
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: 1/27/2022
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSING OF PATIENT WITH YTTRIUM-90 MICROSPHERES
The following was received from the state of Washington via email.
"The patient was scheduled to receive three doses of yttrium-90 microspheres [to the liver], but only the first two doses were successfully administered. However, it appears that only five percent of the final dose was administered, and the rest was caught up in the tubing from the vial. The exact radiation dose administered is not known at this time. The licensee will investigate this event further and provide a written report."
Washington State Incident Number: WA-21-027
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 - UNDERDOSING OF PATIENT WITH YTTRIUM-90 MICROSPHERES
The following was received from the state of Washington via email.
"The patient was scheduled to receive three doses of yttrium-90 microspheres [to the liver], but only the first two doses were successfully administered. However, it appears that only five percent of the final dose was administered, and the rest was caught up in the tubing from the vial. The exact radiation dose administered is not known at this time. The licensee will investigate this event further and provide a written report."
Washington State Incident Number: WA-21-027
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: 55673
Rep Org: Tennessee Div of Rad Health
Licensee: Geoservices, LLC
Region: 1
City: Oneida State: TN
County:
License #: R-47218-11
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Mike Stafford
Licensee: Geoservices, LLC
Region: 1
City: Oneida State: TN
County:
License #: R-47218-11
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Mike Stafford
Notification Date: 12/24/2021
Notification Time: 14:32 [ET]
Event Date: 12/23/2021
Event Time: 00:00 [EST]
Last Update Date: 12/24/2021
Notification Time: 14:32 [ET]
Event Date: 12/23/2021
Event Time: 00:00 [EST]
Last Update Date: 12/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Carfang, Erin (R1)
NMSS_Events_Notification, (EMAIL)
Carfang, Erin (R1)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 1/24/2022
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following was received from the Tennessee Division of Radiological Health via email:
"A dozer ran over a density gauge at a construction site in Oneida, TN. Source was in the shielded position. Licensee was able to fit gauge back into the case and return to their facility.
"Corrective actions will be updated with a report within 30 days."
The gauge contains a 40 mCi Am:Be-241 and an 8 mCi Cs-137 source.
State Event Report ID Number: TN-21-120
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following was received from the Tennessee Division of Radiological Health via email:
"A dozer ran over a density gauge at a construction site in Oneida, TN. Source was in the shielded position. Licensee was able to fit gauge back into the case and return to their facility.
"Corrective actions will be updated with a report within 30 days."
The gauge contains a 40 mCi Am:Be-241 and an 8 mCi Cs-137 source.
State Event Report ID Number: TN-21-120