Event Notification Report for March 31, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/30/2022 - 03/31/2022
Non-Agreement State
Event Number: 55817
Rep Org: Ind Univ-IUPUI/IU Med Center Campus
Licensee: Ind Univ-IUPUI/IU Med Center Campus
Region: 3
City: Indianapolis State: IN
County:
License #: 13-02752-03
Agreement: N
Docket:
NRC Notified By: Michael Martin
HQ OPS Officer: Donald Norwood
Licensee: Ind Univ-IUPUI/IU Med Center Campus
Region: 3
City: Indianapolis State: IN
County:
License #: 13-02752-03
Agreement: N
Docket:
NRC Notified By: Michael Martin
HQ OPS Officer: Donald Norwood
Notification Date: 04/01/2022
Notification Time: 14:25 [ET]
Event Date: 03/31/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/01/2022
Notification Time: 14:25 [ET]
Event Date: 03/31/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/01/2022
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(i) - Lost/Stolen LNM>1000x
10 CFR Section:
20.2201(a)(1)(i) - Lost/Stolen LNM>1000x
Person (Organization):
Kozak, Laura (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Kozak, Laura (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: NON-AGREEMENT STATE REPORT - LOST MEDICAL DOSE
The following information was provided by the licensee via telephone and email:
"Two clinical doses of Xofigo [(radium (Ra-223) dichloride, 119 microcuries)] were delivered to the Nuclear Medicine department on 3/31/2022. A patient scheduled for one of the doses on Thursday 3/31/2022 was successfully administered with the activity. A second patient was scheduled to receive the second dose on 4/1/2022 at 1300 EDT.
"At scheduled time, the Nuclear Medicine technologists could not locate the second dose. After a thorough search, the RSO [(Radiation Safety Officer)] was notified. It is suspected that the second dose was accidentally disposed of in the box in which both doses were received.
"The first dose was properly disposed of in a radioactive sharps container, and the second dose remained in the delivery box within the secured hot lab area. It is suspected that a nuclear medicine technologist threw the box away without realizing a second dose was inside, as it is an extremely rare occurrence for two doses to be delivered concurrently. The dose was not detected during the end of day survey nor by portal monitoring at the waste facility, due to the relatively low activity and low yield of x-rays/gamma-rays (Ra-223 is primarily an alpha emitter)."
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
EN Revision Text: NON-AGREEMENT STATE REPORT - LOST MEDICAL DOSE
The following information was provided by the licensee via telephone and email:
"Two clinical doses of Xofigo [(radium (Ra-223) dichloride, 119 microcuries)] were delivered to the Nuclear Medicine department on 3/31/2022. A patient scheduled for one of the doses on Thursday 3/31/2022 was successfully administered with the activity. A second patient was scheduled to receive the second dose on 4/1/2022 at 1300 EDT.
"At scheduled time, the Nuclear Medicine technologists could not locate the second dose. After a thorough search, the RSO [(Radiation Safety Officer)] was notified. It is suspected that the second dose was accidentally disposed of in the box in which both doses were received.
"The first dose was properly disposed of in a radioactive sharps container, and the second dose remained in the delivery box within the secured hot lab area. It is suspected that a nuclear medicine technologist threw the box away without realizing a second dose was inside, as it is an extremely rare occurrence for two doses to be delivered concurrently. The dose was not detected during the end of day survey nor by portal monitoring at the waste facility, due to the relatively low activity and low yield of x-rays/gamma-rays (Ra-223 is primarily an alpha emitter)."
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Agreement State
Event Number: 55814
Rep Org: WA Office of Radiation Protection
Licensee: Kaiser Permanente Bellevue
Region: 4
City: St. Bellevue State: WA
County:
License #: WN-M021
Agreement: Y
Docket:
NRC Notified By: Morgan Bullock
HQ OPS Officer: Lloyd Desotell
Licensee: Kaiser Permanente Bellevue
Region: 4
City: St. Bellevue State: WA
County:
License #: WN-M021
Agreement: Y
Docket:
NRC Notified By: Morgan Bullock
HQ OPS Officer: Lloyd Desotell
Notification Date: 03/31/2022
Notification Time: 20:48 [ET]
Event Date: 03/31/2022
Event Time: 00:00 [PDT]
Last Update Date: 05/02/2022
Notification Time: 20:48 [ET]
Event Date: 03/31/2022
Event Time: 00:00 [PDT]
Last Update Date: 05/02/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Deese, Rick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (EMAIL)
Deese, Rick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (EMAIL)
EN Revision Imported Date: 5/3/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST GD-153 SOURCE
The following was received from the Washington State Department of Health, Office of Radiation Protection, via email:
"The Washington Agreement State program was notified on 3/31/2022, about a lost source. Kaiser Permanente Bellevue lost a 10 mCi Gd-153 source. The source was in its leaded container in a shipping box and had not been processed in yet to the facility when housekeeping picked it up and threw it away. It then went to their own [trash] compactor and unfortunately was picked up by the garbage company. This event was only discovered a few hours ago.
"Washington State arrived onsite at Kaiser Bellevue at 1300 PDT and spoke with the Director of Imaging. Surveys of the garbage compactor [indicate that] the source is likely intact, as no contamination was found. The source is still lost, but is likely in the company garbage or landfill."
WA incident no.: WA-022-006
* * * UPDATE ON 05/02/2022 AT 1526 EDT FROM TRISTAN HAY TO LLOYD DESOTELL * * *
The following update was received from the state of Washington via email:
"Based on their [licensee] corrective actions we [the state of Washington] have closed the incident. The lost source will most likely not be findable due to it making it into the landfill already and still being in its shielded container. "
Notified R4DO (Warnick) and ILTAB, NMSS Events Notification and CNSC via email.
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
EN Revision Text: AGREEMENT STATE REPORT - LOST GD-153 SOURCE
The following was received from the Washington State Department of Health, Office of Radiation Protection, via email:
"The Washington Agreement State program was notified on 3/31/2022, about a lost source. Kaiser Permanente Bellevue lost a 10 mCi Gd-153 source. The source was in its leaded container in a shipping box and had not been processed in yet to the facility when housekeeping picked it up and threw it away. It then went to their own [trash] compactor and unfortunately was picked up by the garbage company. This event was only discovered a few hours ago.
"Washington State arrived onsite at Kaiser Bellevue at 1300 PDT and spoke with the Director of Imaging. Surveys of the garbage compactor [indicate that] the source is likely intact, as no contamination was found. The source is still lost, but is likely in the company garbage or landfill."
WA incident no.: WA-022-006
* * * UPDATE ON 05/02/2022 AT 1526 EDT FROM TRISTAN HAY TO LLOYD DESOTELL * * *
The following update was received from the state of Washington via email:
"Based on their [licensee] corrective actions we [the state of Washington] have closed the incident. The lost source will most likely not be findable due to it making it into the landfill already and still being in its shielded container. "
Notified R4DO (Warnick) and ILTAB, NMSS Events Notification and CNSC via email.
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf