Event Notification Report for July 28, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
07/27/2022 - 07/28/2022

EVENT NUMBERS
56006 56007 56008 56009
Agreement State
Event Number: 56006
Rep Org: Ohio Bureau of Radiation Protection
Licensee: Kettering Health Network
Region: 3
City: Kettering   State: OH
County:
License #: 02110580000
Agreement: Y
Docket:
NRC Notified By: Michael Rubadue
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 07/21/2022
Notification Time: 14:15 [ET]
Event Date: 07/19/2022
Event Time: 00:00 [EDT]
Last Update Date: 07/21/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Kunowski, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
The following information was provided by the licensee via email:

AGREEMENT STATE REPORT - SURFACE CONTAMINATION LEVELS EXCEEDED LIMITS FOR PACKAGE

"The licensee, Kettering Health Network, shipped a package containing F-18 FDG [Fluorodeoxyglucose] from their PET [positron emission tomography] manufacturing facility to another hospital listed on their license. Receipt surveys of the package were 110 mR/hr at the surface and 1,050,000 dpm removable. Surveys of the package prior to shipment were 3 mR/hr contact and 210 dpm removable. The licensee uses a radiopharmaceutical company to transport packages. The transport company was notified.

"Surveys of the PET production facility and transport vehicle have been conducted. No contamination was discovered."

Ohio Department of Health - Item Number: OH220008


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
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
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Schroeder, Dan (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
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.


Agreement State
Event Number: 56008
Rep Org: Colorado Dept of Health
Licensee: Brookedale
Region: 4
City: Denver   State: CO
County:
License #: GL000578
Agreement: Y
Docket:
NRC Notified By: Kathryn Kirk
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 07/21/2022
Notification Time: 15:15 [ET]
Event Date: 06/28/2022
Event Time: 00:00 [MDT]
Last Update Date: 07/21/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Gaddy, Vincent (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT- LOST EXIT SIGN

The following summary was received from the Colorado Department of Public Health and Environment via email:

The Colorado Department of Public Health and Environment reported one model BX15BK exit sign containing 15 curies of tritium lost by the licensee. The incident occurred June 28, 2022.

CO Event Report ID no.: CO220023

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: 56009
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: G.E. Healthcare DBA/ Medi+Physics
Region: 3
City: Arlington Heights   State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 07/21/2022
Notification Time: 16:13 [ET]
Event Date: 07/21/2022
Event Time: 00:00 [CDT]
Last Update Date: 07/21/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Kunowski, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Schroeder, Dan (R1DO)
ILTAB, (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOST RADIOPHARMACEUTICAL PACKAGES

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

"The Agency was notified on July 21, 2022, by GE Healthcare that four distinct packages (different shipments) were declared as lost while in the care of a common carrier. All four packages contained millicurie quantities of radiopharmaceuticals and were labeled Yellow-II and were last known to be at the carrier's shipping hub in Memphis, TN. All packages were labeled Yellow-II and shipped in a 16cm x 16cm corrugated box from the licensee's facility in Arlington Heights, IL. Package 1 was shipped July 12, 2022, and contained 14.268 mCi of I-123, in route to New Hampshire. Package 2 was shipped July 14, 2022, and contained 4.089 mCi of In-111, in route to California. Package 3 was shipped July 14, 2022, and contained 12.268 mCi of In-111, in route to Florida. Package 4 was shipped July 20, 2022 and contained 0.941 mCi of In-111, in route to Florida. NOTE: The box for Package 4 was located, but its contents are missing. The licensee made timely notification to the Agency. Tennessee program staff will be notified as well."

Item Number: IL220025

THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

Page Last Reviewed/Updated Thursday, July 28, 2022