Event Notification Report for February 11, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/10/2022 - 02/11/2022
Agreement State
Event Number: 55740
Rep Org: PA Bureau of Radiation Protection
Licensee: Northeast Radiation Oncology Center
Region: 1
City: Dunmore State: PA
County:
License #: PA-1541
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Mike Stafford
Licensee: Northeast Radiation Oncology Center
Region: 1
City: Dunmore State: PA
County:
License #: PA-1541
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Mike Stafford
Notification Date: 02/16/2022
Notification Time: 10:38 [ET]
Event Date: 02/11/2022
Event Time: 00:00 [EST]
Last Update Date: 02/16/2022
Notification Time: 10:38 [ET]
Event Date: 02/11/2022
Event Time: 00:00 [EST]
Last Update Date: 02/16/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Schroeder, Dan (R1)
NMSS_Events_Notification, (EMAIL)
Rivera-Capella, Gretchen (NMSS DAY)
Schroeder, Dan (R1)
NMSS_Events_Notification, (EMAIL)
Rivera-Capella, Gretchen (NMSS DAY)
EN Revision Imported Date: 3/16/2022
EN Revision Text: AGREEMENT STATE REPORT - DOSE TO AN INCORRECT TREATMENT SITE
The following report was received from the Pennsylvania Department of Bureau Radiation Protection (the Department) via email:
"The Department [DEP] received notification from a licensee on February 15, 2022, of medical event involving dose to an incorrect treatment site. An Elekta/Nucletron Remote Afterloader containing 6.421 Curies of iridium 192 (serial number V3/ 10799) with a Valencia skin applicator was to treat the lower third nasal dorsum with 600 cGy. However, the prescribing physician specified the right nasal sidewall. Therefore, the patient received 600 cGy to her lower 3rd nasal dorsum and not right nasal sidewall. The patient and prescribing physician were informed on February 14, 2022. The patient is being monitored and at this time no adverse effects are evident. The DEP is currently in contact with the licensee and will update this event as soon as more information is provided."
Pennsylvania Event Report Number: PA220007
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 - DOSE TO AN INCORRECT TREATMENT SITE
The following report was received from the Pennsylvania Department of Bureau Radiation Protection (the Department) via email:
"The Department [DEP] received notification from a licensee on February 15, 2022, of medical event involving dose to an incorrect treatment site. An Elekta/Nucletron Remote Afterloader containing 6.421 Curies of iridium 192 (serial number V3/ 10799) with a Valencia skin applicator was to treat the lower third nasal dorsum with 600 cGy. However, the prescribing physician specified the right nasal sidewall. Therefore, the patient received 600 cGy to her lower 3rd nasal dorsum and not right nasal sidewall. The patient and prescribing physician were informed on February 14, 2022. The patient is being monitored and at this time no adverse effects are evident. The DEP is currently in contact with the licensee and will update this event as soon as more information is provided."
Pennsylvania Event Report Number: PA220007
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: 55738
Rep Org: Arkansas Department of Health
Licensee: Clearwater Paper Corporation
Region: 4
City: State: AR
County:
License #: ARK-0530
Agreement: Y
Docket:
NRC Notified By: Christy Steward
HQ OPS Officer: Thomas Herrity
Licensee: Clearwater Paper Corporation
Region: 4
City: State: AR
County:
License #: ARK-0530
Agreement: Y
Docket:
NRC Notified By: Christy Steward
HQ OPS Officer: Thomas Herrity
Notification Date: 02/11/2022
Notification Time: 16:17 [ET]
Event Date: 02/11/2022
Event Time: 17:38 [CST]
Last Update Date: 02/11/2022
Notification Time: 16:17 [ET]
Event Date: 02/11/2022
Event Time: 17:38 [CST]
Last Update Date: 02/11/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Kellar, Ray (R4)
NMSS_Events_Notification, (EMAIL)
Kellar, Ray (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 3/11/2022
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER
The following information was received from the Arkansas Department of Health, Radiation Control:
"On February 11, 2022, Clearwater Paper Corporation notified ADH Radiation Control that a gauge had a stuck shutter. During routine leak tests on February 10, 2022, the licensee noted that the shutter would not close. The gauge is identified as a Berthold Model LB 300 L source holder containing 1.54 milliCuries of Cobalt-60. The gauge remains in the normal use location with signage.
"The licensee has contacted the vendor who stated that this model is no longer available. The licensee intends to research an applicable replacement.
"In accordance with RH-1502.f.2 (10 CFR 30.50(b)(2)), the malfunctioning shutter is reportable within 24 hours. The State of Arkansas is awaiting a written report from the licensee and final disposition information for the gauge."
Arkansas Event Number: AR-2022-02
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER
The following information was received from the Arkansas Department of Health, Radiation Control:
"On February 11, 2022, Clearwater Paper Corporation notified ADH Radiation Control that a gauge had a stuck shutter. During routine leak tests on February 10, 2022, the licensee noted that the shutter would not close. The gauge is identified as a Berthold Model LB 300 L source holder containing 1.54 milliCuries of Cobalt-60. The gauge remains in the normal use location with signage.
"The licensee has contacted the vendor who stated that this model is no longer available. The licensee intends to research an applicable replacement.
"In accordance with RH-1502.f.2 (10 CFR 30.50(b)(2)), the malfunctioning shutter is reportable within 24 hours. The State of Arkansas is awaiting a written report from the licensee and final disposition information for the gauge."
Arkansas Event Number: AR-2022-02