Event Notification Report for July 20, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/19/2022 - 07/20/2022
Agreement State
Event Number: 56007
Rep Org: Georgia Radioactive Material Pgm
Licensee: Emory University
Region: 1
City: Atlanta State: GA
County:
License #: GA 153-1
Agreement: Y
Docket:
NRC Notified By: John Hays
HQ OPS Officer: Karen Cotton-Gross
Licensee: Emory University
Region: 1
City: Atlanta State: GA
County:
License #: GA 153-1
Agreement: Y
Docket:
NRC Notified By: John Hays
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 07/21/2022
Notification Time: 15:01 [ET]
Event Date: 07/20/2022
Event Time: 00:00 [EDT]
Last Update Date: 07/21/2022
Notification Time: 15:01 [ET]
Event Date: 07/20/2022
Event Time: 00:00 [EDT]
Last Update Date: 07/21/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Schroeder, Dan (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Schroeder, Dan (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DOSE MISADMINISTRATION
The following information was provided by the licensee via email:
"This is a preliminary report. A male patient was prescribed 100 millicuries of lutetium-177. He was delivered with 204 millicuries instead on July 20. This was the patient's third round of lutetium-177. The first two rounds were delivered at 100 millicuries as prescribed. Patient has been notified of the misadministration per a phone call from the prescribing physician. Emory University will send a more thorough report of the misadministration. More information is to follow."
Georgia Incident No: 55
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.
The following information was provided by the licensee via email:
"This is a preliminary report. A male patient was prescribed 100 millicuries of lutetium-177. He was delivered with 204 millicuries instead on July 20. This was the patient's third round of lutetium-177. The first two rounds were delivered at 100 millicuries as prescribed. Patient has been notified of the misadministration per a phone call from the prescribing physician. Emory University will send a more thorough report of the misadministration. More information is to follow."
Georgia Incident No: 55
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: 56207
Rep Org: New York State Dept. of Health
Licensee:
Region: 1
City: State: NY
County:
License #: 0509
Agreement: Y
Docket:
NRC Notified By: Daniel Samson
HQ OPS Officer: Karen Cotton-Gross
Licensee:
Region: 1
City: State: NY
County:
License #: 0509
Agreement: Y
Docket:
NRC Notified By: Daniel Samson
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 11/04/2022
Notification Time: 13:26 [ET]
Event Date: 07/20/2022
Event Time: 00:00 [EDT]
Last Update Date: 11/04/2022
Notification Time: 13:26 [ET]
Event Date: 07/20/2022
Event Time: 00:00 [EDT]
Last Update Date: 11/04/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
CNSC (Canada), - (EMAIL)
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
CNSC (Canada), - (EMAIL)
AGREEMENT STATE REPORT - LOST LICENSED MATERIAL (MEDICAL SEEDS)
The following information was provided by the New York State Department of Health (the Department) via fax:
"On August 16, 2022, the Department was notified of a missing I-125 localization seed (lsoAid I-125, Serial No. 78315 Activity: 0.025 millicurie) at a licensed medical facility in New York.
"On July 18, 2022, there were two patients, one seed in each of 2 patients was removed. Radiograph of the specimens showed seeds and biopsy clips were present. On July 20, 2022, the Nuclear Medicine technologist was called to retrieve the 2 seeds in a leaded container. Upon further survey, the technologist discovered there was only one seed, and the other was a biopsy clip. The Nuclear Medical Technologist surveyed the pathology lab, including benches, trash and floor but was then informed that the seeds were retrieved from the specimens the day before on July 19, 2022. The laboratory manager, radiology manager and nuclear medicine technologist tracked the path of seeds including the pathology lab, the operating room and hallways. Radioactive trash was also surveyed for radioactivity. The Radiation Safety Office and Medical Physicist were then notified of the missing seed.
"Corrective actions are in place including:
1. Nuclear Medicine will be notified immediately when a seed is retrieved from a specimen.
2. When retrieving the seed from the specimen, the survey meter must be used to ensure the seed is present.
3. Temporary pathology workers will not work with radioactive seeds.
"NY Event Report ID: NYDOH-22-06"
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
The following information was provided by the New York State Department of Health (the Department) via fax:
"On August 16, 2022, the Department was notified of a missing I-125 localization seed (lsoAid I-125, Serial No. 78315 Activity: 0.025 millicurie) at a licensed medical facility in New York.
"On July 18, 2022, there were two patients, one seed in each of 2 patients was removed. Radiograph of the specimens showed seeds and biopsy clips were present. On July 20, 2022, the Nuclear Medicine technologist was called to retrieve the 2 seeds in a leaded container. Upon further survey, the technologist discovered there was only one seed, and the other was a biopsy clip. The Nuclear Medical Technologist surveyed the pathology lab, including benches, trash and floor but was then informed that the seeds were retrieved from the specimens the day before on July 19, 2022. The laboratory manager, radiology manager and nuclear medicine technologist tracked the path of seeds including the pathology lab, the operating room and hallways. Radioactive trash was also surveyed for radioactivity. The Radiation Safety Office and Medical Physicist were then notified of the missing seed.
"Corrective actions are in place including:
1. Nuclear Medicine will be notified immediately when a seed is retrieved from a specimen.
2. When retrieving the seed from the specimen, the survey meter must be used to ensure the seed is present.
3. Temporary pathology workers will not work with radioactive seeds.
"NY Event Report ID: NYDOH-22-06"
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