Event Notification Report for March 22, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/21/2022 - 03/22/2022
EVENT NUMBERS
55812
55812
Agreement State
Event Number: 55812
Rep Org: Oregon Health Authority
Licensee: Salem Hospital
Region: 4
City: Salem State: OR
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Daryl A. Leon
HQ OPS Officer: Karen Cotton-Gross
Licensee: Salem Hospital
Region: 4
City: Salem State: OR
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Daryl A. Leon
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 03/31/2022
Notification Time: 12:56 [ET]
Event Date: 03/22/2022
Event Time: 00:00 [PDT]
Last Update Date: 03/31/2022
Notification Time: 12:56 [ET]
Event Date: 03/22/2022
Event Time: 00:00 [PDT]
Last Update Date: 03/31/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Deese, Rick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Deese, Rick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST/RECOVERED SOURCE
The following information was provided by the Oregon Health Authority via email:
"On March 22, 2022, a High Dose Rate Delivery (HDR) sealed source of Iridium-192 was delivered by a common carrier to the wrong floor and clinic in a licensed (Salem Hospital) hospital. Instead of the shipping destination (given as Radiation Oncology/Attn: Dr xxx) on the 1st floor, the package was delivered to the 4th floor of the same building. The person receiving the package, who does not have radiation safety or transportation training, signed for it without an understanding of what it was and placed it on the floor of an access-controlled staff working area.
"On March 28, 2022, the licensee received an email request from the vendor (Varian) to schedule a date/time for installation of the new source. It was at this time that the licensee realized that the source had not arrived at their location and found the source had been delivered on March 22, 2022. An investigation was initiated and the source package was located in the 4th floor clinic. The package was surveyed and observed to be intact with no evidence of tampering . The transport index for the Type A Yellow -II package was noted at 0.9. The package was taken to the licensee's office and secured in locked storage.
"The licensee evaluated the dose received by clinic staff working in the proximity of the package. Clinic staff does not work a full shift in the area (five hours maximum/day) and the closest estimated distance from the package was measured at 2 feet (60 cm). The exposure period was 5 working days. The licensee performed dose measurements on and near the source package at various distances and orientations with a survey meter. The maximum dose received was while sitting in a chair and was calculated to be 0.4 mR/hr.
"Total dose received was given as:
0.4 mR/hr * 5 hrs/day * 5 days = 10 mR total exposure (~10 mrem or 0.01 rem equivalent dose). This dose-risk standard was based upon National Council on Radiation Protection and Measurements (NCRP) Report No. 91.
"Cause and corrective actions :
"The two subsequent causes are of the same nature, human error. First, the carrier failed to deliver the package to the labeled destination and person. Second, the hospital clinic signed for the package without checking the proper destination or person it was intended for. A potential third cause of human error is that the licensee failed to check on package delivery sooner if a tracking number was associated with this shipment. Corrective actions have not been instituted at this time since not all information has been collected for this event. The licensee indicated that they receive these shipments quarterly and wait for the vendor to schedule an installation. There was no indication given of tracking a replacement source package while it is in transit to the licensee's site. This is being investigated further.
"Information regarding the source activity, manufacturer, model, serial number and leak test date will be provided to the NRC Headquarters Operation Center when it is received from the Licensee."
Oregon Report Identification Number: 22-0016
EN Revision Text: AGREEMENT STATE REPORT - LOST/RECOVERED SOURCE
The following information was provided by the Oregon Health Authority via email:
"On March 22, 2022, a High Dose Rate Delivery (HDR) sealed source of Iridium-192 was delivered by a common carrier to the wrong floor and clinic in a licensed (Salem Hospital) hospital. Instead of the shipping destination (given as Radiation Oncology/Attn: Dr xxx) on the 1st floor, the package was delivered to the 4th floor of the same building. The person receiving the package, who does not have radiation safety or transportation training, signed for it without an understanding of what it was and placed it on the floor of an access-controlled staff working area.
"On March 28, 2022, the licensee received an email request from the vendor (Varian) to schedule a date/time for installation of the new source. It was at this time that the licensee realized that the source had not arrived at their location and found the source had been delivered on March 22, 2022. An investigation was initiated and the source package was located in the 4th floor clinic. The package was surveyed and observed to be intact with no evidence of tampering . The transport index for the Type A Yellow -II package was noted at 0.9. The package was taken to the licensee's office and secured in locked storage.
"The licensee evaluated the dose received by clinic staff working in the proximity of the package. Clinic staff does not work a full shift in the area (five hours maximum/day) and the closest estimated distance from the package was measured at 2 feet (60 cm). The exposure period was 5 working days. The licensee performed dose measurements on and near the source package at various distances and orientations with a survey meter. The maximum dose received was while sitting in a chair and was calculated to be 0.4 mR/hr.
"Total dose received was given as:
0.4 mR/hr * 5 hrs/day * 5 days = 10 mR total exposure (~10 mrem or 0.01 rem equivalent dose). This dose-risk standard was based upon National Council on Radiation Protection and Measurements (NCRP) Report No. 91.
"Cause and corrective actions :
"The two subsequent causes are of the same nature, human error. First, the carrier failed to deliver the package to the labeled destination and person. Second, the hospital clinic signed for the package without checking the proper destination or person it was intended for. A potential third cause of human error is that the licensee failed to check on package delivery sooner if a tracking number was associated with this shipment. Corrective actions have not been instituted at this time since not all information has been collected for this event. The licensee indicated that they receive these shipments quarterly and wait for the vendor to schedule an installation. There was no indication given of tracking a replacement source package while it is in transit to the licensee's site. This is being investigated further.
"Information regarding the source activity, manufacturer, model, serial number and leak test date will be provided to the NRC Headquarters Operation Center when it is received from the Licensee."
Oregon Report Identification Number: 22-0016