Event Notification Report for March 10, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/09/2022 - 03/10/2022
Agreement State
Event Number: 55782
Rep Org: Florida Bureau of Radiation Control
Licensee: H. Lee Moffitt Cancer Center
Region: 1
City: Tampa State: FL
County: Hillsborough
License #: 1739-1
Agreement: Y
Docket:
NRC Notified By: Chris Brosius
HQ OPS Officer: Dan Livermore
Licensee: H. Lee Moffitt Cancer Center
Region: 1
City: Tampa State: FL
County: Hillsborough
License #: 1739-1
Agreement: Y
Docket:
NRC Notified By: Chris Brosius
HQ OPS Officer: Dan Livermore
Notification Date: 03/10/2022
Notification Time: 17:22 [ET]
Event Date: 03/10/2022
Event Time: 10:00 [EST]
Last Update Date: 03/10/2022
Notification Time: 17:22 [ET]
Event Date: 03/10/2022
Event Time: 10:00 [EST]
Last Update Date: 03/10/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/8/2022
EN Revision Text: AGREEMENT STATE - LUTATHERA TREATMENT TERMINATED DUE TO INFUSION LINE LEAK
The following information was provided by the Florida Bureau of Radiation Control (FL BRC) via email:
"Today, 3/10/2022, at 1000 EST, Lutathera treatment was started in a controlled infusion room within the nuclear medicine department of Moffitt Cancer Center with an initial vial assay of 206 mCi, approximately two minutes later the NMT [(nuclear medicine technologist)] noticed a leak in the infusion line and stopped the infusion. Assistance was provided by a fellow technologist and the vial of Lutathera (Lu-177) was re-assayed at 130 mCi. The floor lead technologist notified the prescribing physician and the physician decided to terminate the treatment and to re-treat at a later date. Wipe tests performed by the technologists on the patient including the arm where the IV was showed no evidence of removable contamination. The department supervisor was notified and called the radiation safety officer (RSO) at 1030 EST. The IV was removed from the patient and the tubing was assayed at 36 mCi. The infusion room was surveyed and appropriately decontaminated. Residual waste from decontamination, as well as the vial, lead vial container, and IV/tubing were logged, labeled, and placed into secure storage. An investigation into the cause of the incident will be completed, and corrective actions will be implemented to prevent reoccurrence.
"The prescribing physician spoke with the patient and explained what happened and that there would not be any clinical impact on the patient and no medical risks.
"The referring physician was notified.
"A written report will be provided to the FL BRC, the referring physician, and the individual within 15 days of this event in accordance to 64E-5.345 4(b)."
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 - LUTATHERA TREATMENT TERMINATED DUE TO INFUSION LINE LEAK
The following information was provided by the Florida Bureau of Radiation Control (FL BRC) via email:
"Today, 3/10/2022, at 1000 EST, Lutathera treatment was started in a controlled infusion room within the nuclear medicine department of Moffitt Cancer Center with an initial vial assay of 206 mCi, approximately two minutes later the NMT [(nuclear medicine technologist)] noticed a leak in the infusion line and stopped the infusion. Assistance was provided by a fellow technologist and the vial of Lutathera (Lu-177) was re-assayed at 130 mCi. The floor lead technologist notified the prescribing physician and the physician decided to terminate the treatment and to re-treat at a later date. Wipe tests performed by the technologists on the patient including the arm where the IV was showed no evidence of removable contamination. The department supervisor was notified and called the radiation safety officer (RSO) at 1030 EST. The IV was removed from the patient and the tubing was assayed at 36 mCi. The infusion room was surveyed and appropriately decontaminated. Residual waste from decontamination, as well as the vial, lead vial container, and IV/tubing were logged, labeled, and placed into secure storage. An investigation into the cause of the incident will be completed, and corrective actions will be implemented to prevent reoccurrence.
"The prescribing physician spoke with the patient and explained what happened and that there would not be any clinical impact on the patient and no medical risks.
"The referring physician was notified.
"A written report will be provided to the FL BRC, the referring physician, and the individual within 15 days of this event in accordance to 64E-5.345 4(b)."
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: 55794
Rep Org: Georgia Radioactive Material Pgm
Licensee: Brunswick Cellulose, LLC
Region: 1
City: Brunswick State: GA
County:
License #: GA 301-1
Agreement: Y
Docket:
NRC Notified By: Avionne Fortner
HQ OPS Officer: Mike Stafford
Licensee: Brunswick Cellulose, LLC
Region: 1
City: Brunswick State: GA
County:
License #: GA 301-1
Agreement: Y
Docket:
NRC Notified By: Avionne Fortner
HQ OPS Officer: Mike Stafford
Notification Date: 03/18/2022
Notification Time: 12:01 [ET]
Event Date: 03/10/2022
Event Time: 00:00 [EST]
Last Update Date: 03/18/2022
Notification Time: 12:01 [ET]
Event Date: 03/10/2022
Event Time: 00:00 [EST]
Last Update Date: 03/18/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Henrion, Mark (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Henrion, Mark (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER FAILED IN THE OPEN POSITION
The following is a synopsis of an email received the Georgia Radioactive Materials Program (the department):
On March 10, 2022, the department received an email from the licensee's radiation safety officer (RSO), reporting a failed shutter on one of their sealed nuclear sources that occurred during their routine, semi-annual gauge inspection. The gauge contained 5 mCi Cs-137. The licensee performed a surface survey with readings in a 1 ft. radius. The readings ranged from 0.01 mR/hr to 0.1 mR/hr. The licensee also performed a leak test with results still pending. The licensee plans to dispose of the faulty gauge. No one was exposed during this incident.
Georgia Incident Number: 51
EN Revision Text: AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER FAILED IN THE OPEN POSITION
The following is a synopsis of an email received the Georgia Radioactive Materials Program (the department):
On March 10, 2022, the department received an email from the licensee's radiation safety officer (RSO), reporting a failed shutter on one of their sealed nuclear sources that occurred during their routine, semi-annual gauge inspection. The gauge contained 5 mCi Cs-137. The licensee performed a surface survey with readings in a 1 ft. radius. The readings ranged from 0.01 mR/hr to 0.1 mR/hr. The licensee also performed a leak test with results still pending. The licensee plans to dispose of the faulty gauge. No one was exposed during this incident.
Georgia Incident Number: 51