Event Notification Report for April 20, 2022

EN Revision Imported Date: 4/15/2022

EN Revision Text: AGREEMENT STATE REPORT - FAILURE OF A COMPONENT OF THE ACCESS CONTROL SYSTEM

The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:

"At 0920 CDT on 4/12/2022, the Corporate Radiation Safety Officer (RSO) at Isomedix Operations, Inc. called to report a failure of the electronic brake on the irradiator vault entrance door located in Libertyville. The failure was discovered by licensee personnel at 1200 CDT on 4/11/2022. The licensee stated that operations were discontinued at this time. Following trouble shooting and diagnosis of the issue, the failure was reported to the Corporate RSO at 1830 CDT that same day. The licensee reinitiated operations after implementing temporary remedial access control measures and completing training of staff on revised procedures.

"As of 1030 CDT on 4/12/2022, the licensee was advised to cease operation of the affected irradiator until further notice. Agency inspectors were dispatched on 4/12/2022 to perform a reactionary inspection. The event was called into the [NRC Headquarters Operations Officer] as required.

"No personnel injuries or exposures and no adverse effects on the security system were reported."

Item Number: IL220011

EN Revision Imported Date: 4/15/2022

EN Revision Text: AGREEMENT STATE REPORT - SOURCE NOT SECURE WITHIN GAUGE

The following information was received from the Texas Department of State Health Services (the Agency) via E-mail:

"On April 12, 2022, the Agency received an email from a licensee regarding an Am-241 source that was no longer within the source holder of a Troxler Model 3430 (source assay date 9/29/1997 and serial 28367). The source capsule, source holder, and source cap were all loose within the gauge. This was the first notification to this Agency of this issue. The licensee reported that on March 25, 2022, a licensee technician reported measurement issues with this device. A survey of the device did not find any elevated readings. The device was pulled from service and inspected on March 30, 2022, at which point the loose components were discovered. This licensee had experience with this issue before (see EN 55774) and repaired the assembly using Loctite.
Licensee reports the source is not leaking and is secured within the source holder. Investigation is ongoing and additional information will be provided per SA-300."

Texas Incident Number: I-9925

EN Revision Imported Date: 4/15/2022

EN Revision Text: AGREEMENT STATE REPORT - PATIENT RECEIVED DOSE GREATER THAN PRESCRIBED

The following was received from the State of California, Department of Public Health, Radiologic Health Branch, via email:

"The Radiologic Health Branch was notified on April 12, 2022 regarding a medical event that occurred on April 11, 2022 at Loma Linda University Health. An authorized user was performing Y-90 brachytherapy using Nordion TheraSpheres on a patient's liver. After catheterizing and delivering Y-90 to the first segment, it was discovered that due to the patient's variant anatomy, the segment had been misidentified. The written directive called for 2.228 GBq to deliver 950 Gy to the patient's liver segment 7. However, post treatment analysis of the source vial determined that 2.840 GBq (76.7 mCi) was delivered. As a result, the dose delivered to that segment was approximately 27 percent above the dose specified in the written directive. A 15-day report will be generated by the licensee per 10 CFR 35.3045."

California Event Number: 041222

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 Imported Date: 4/15/2022

EN Revision Text: FITNESS FOR DUTY

The following information was provided by the licensee via email:

Two contract employees admitted to being involved in the use, sale, or possession of a controlled substance. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified.

EN Revision Imported Date: 4/15/2022

EN Revision Text: AGREEMENT STATE REPORT - PATIENT RECEIVED DOSE LESS THAN PRESCRIBED

The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:

"The Radiation Safety Officer for Northwestern Memorial HealthCare, contacted the Agency on 4/12/2022 to advise of a Y-90 microsphere administration in which the patient received only 70 percent of the prescribed dose. Of note, the [authorized user] noticed sluggish flow during the first flush of saline through the device, possibly due to a kink in the micro catheter as it exits the base catheter. No contamination or other issues were identified. No adverse patient impacts are expected. The [authorized user] was satisfied that the dose was adequate as delivered and will assess with MRI in 1 month as per protocol. The Agency will dispatch inspectors to review procedures and determine a root cause."

Item Number: IL220012

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.

FITNESS-FOR-DUTY REPORT - FAILED FITNESS-FOR-DUTY TEST

The following information was provided by the licensee via email:
A contract employee supervisor had a confirmed positive for illegal drugs during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The licensee notified the NRC Resident Inspector.