Report a Safety Concern
Search

The U.S. Nuclear Regulatory Commission is in the process of rescinding or revising guidance and policies posted on this webpage in accordance with Executive Order 14151 Ending Radical and Wasteful Government DEI Programs and Preferencing, and Executive Order 14168 Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government. In the interim, any previously issued diversity, equity, inclusion, or gender-related guidance on this webpage should be considered rescinded that is inconsistent with these Executive Orders.

Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2022

Event Notification Report for February 04, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
02/03/2022 - 02/04/2022

EVENT NUMBERS
55714 55716 55717
Agreement State
Event Number: 55714
Rep Org: PA Bureau of Radiation Protection
Licensee: University of Pennsylvania, Philadelphia, PA
Region: 1
City: Philadelphia   State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Donald Norwood
Notification Date: 01/27/2022
Notification Time: 11:09 [ET]
Event Date: 01/25/2022
Event Time: 00:00 [EST]
Last Update Date: 01/27/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Gray, Mel (R1)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 2/4/2022

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received via E-mail:

"On January 26, 2022 the licensee informed the Department (Department of Environmental Protection) of a medical event. It is reportable as per 10 CFR 35.3045(a)(1)(i).

"The Department received notification from a licensee on January 26, 2022 of a medical event involving Yttium-90 TheraSpheres. The entire procedure occurred without incident and the routine contamination survey identified no contamination. However, when the waste was measured following the procedure, the percent of prescribed activity administered was 70.6 percent (administered = 27.72 mCi, prescribed activity = 39.24 mCi). No harm is expected to the patient.

"No further information is available at this time. The Department is currently in contact with the licensee and will update this event as soon as more information is provided."

Pennsylvania Event Report ID No.: PA220002

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: 55716
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Northwestern Memorial Hospital
Region: 3
City: Chicago   State: IL
County:
License #: IL-01037-02
Agreement: Y
Docket:
NRC Notified By: Robin Muzzalupo
HQ OPS Officer: Thomas Kendzia
Notification Date: 01/28/2022
Notification Time: 17:00 [ET]
Event Date: 01/27/2022
Event Time: 00:00 [CST]
Last Update Date: 01/28/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Orth, Steve (R3)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 2/4/2022

EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following information was received from Illinois Emergency Management Agency (Agency) via phone and E-mail:

"At 1545 CST on 1/27/2022, the Agency was contacted by Northwestern Memorial Hospital (IL-01037-02) of a potential medical event. No adverse patient impact reported. The administration was able to be completed that same day. This event was reported to the NRC Headquarters Operations Officer (1/28/22) this afternoon.

"Agency inspectors performed a reactive inspection on 1/28/2022 at Central DuPage Hospital. On 1/27/2022, a written directive to deliver 3.25 GBq Y-90 SIR-Spheres to the right hepatic artery was prepared. The procedure performed that same day was halted prematurely due to an occlusion of microspheres in the delivery line. [Surveys of the delivery equipment indicated no microspheres were delivered to the patient.] To compensate for the underdose, the licensee created two additional written directives and administered two doses of 1.55 GBq Y-90 SIR-Spheres each without incident.

"The licensee is continuing their investigation into root cause. [Agency will review the investigation results.]"

Item Number: IL220002

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: 55717
Rep Org: California Radiation Control Prgm
Licensee: Mistras Group, Inc.
Region: 4
City: Benicia   State: CA
County:
License #: 4886-48
Agreement: Y
Docket:
NRC Notified By: Arunika Hewadikaram
HQ OPS Officer: Thomas Kendzia
Notification Date: 01/28/2022
Notification Time: 19:08 [ET]
Event Date: 01/27/2022
Event Time: 21:00 [PST]
Last Update Date: 01/28/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Josey, Jeffrey (R4)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 2/4/2022

EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA EQUIPMENT FAILURE

The following report was received from the California Department of Public Health (RHB) via email:

"On 1/28/2022, the licensee notified RHB of an incident in which an INC IR-100 (S/N 4314) radiography exposure device, containing 92 Ci of Ir-192 QSA Global source (S/N 57551M), prematurely actuated its safety latch plate when retracting the Ir-192 source to the fully shielded position resulting in the source assembly stop ball being on the wrong side of the safety latch plate. The source assembly was eventually returned to the fully shielded position by the RSO [radiation safety officer]. The maximum dose recorded on the crews' pocket dosimeter was 7 mR. The incident occurred on 1/27/2022 at approximately 2100 PST at the MRC refinery in Martinez, CA. On 1/28/2022 licensee had taken the camera back to INC for evaluation. RHB will be investigating this incident further."

California Event Number: 012822