Event Notification Report for August 22, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/21/2022 - 08/22/2022
Agreement State
Event Number: 56064
Rep Org: MA Radiation Control Program
Licensee: Dana Farber Cancer Institute
Region: 1
City: Boston State: MA
County:
License #: 60-0037
Agreement: Y
Docket:
NRC Notified By: Joshua E. Daehler
HQ OPS Officer: Karen Cotton-Gross
Licensee: Dana Farber Cancer Institute
Region: 1
City: Boston State: MA
County:
License #: 60-0037
Agreement: Y
Docket:
NRC Notified By: Joshua E. Daehler
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 08/24/2022
Notification Time: 11:09 [ET]
Event Date: 08/22/2022
Event Time: 00:00 [EDT]
Last Update Date: 08/24/2022
Notification Time: 11:09 [ET]
Event Date: 08/22/2022
Event Time: 00:00 [EDT]
Last Update Date: 08/24/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - UNINTENDED DOSE TO FETUS
The following information was provided by the Massachusetts Radiation Control Program (The Agency) via email:
"The licensee ( Dana Farber Cancer Institute) reported by telephone on August 23, 2022, that it discovered on August 22, 2022, that it had administered on August 22, 2022, a radiopharmaceutical (10 millicuries of F-18 FDG) as part of a PET/CT diagnostic procedure to a patient that was unknowingly pregnant resulting in an estimated dose to the embryo/fetus of 20 milli-gray (20 millisievert or 2 rem). The estimated dose is inclusive of both the F-18 PET and CT components of the procedure.
"The reporting requirement is 105 CMR 120.594(B), Report and Notification of a Dose to an Embryo/Fetus or Nursing Child, a by no later than next calendar day of the event telephone report.
"The licensee reported that pregnancy screening questions were answered through an interpreter, stating that the patient was not pregnant and that the result of the PET/CT scan showed that the patient was pregnant.
"The licensee reported that the referring physician and the patient have been notified. The licensee reported that at this time (August 23, 2022) there is no expectation of physical/deterministic harm to the fetus from the dose received.
"The licensee reported that a written report will be submitted to the Agency within 15 days of the telephone report in accordance with 105 CMR 120.594(B)(4).
"The Agency considers this event to be open."
Massachusetts Event Number: 20-5109
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 Massachusetts Radiation Control Program (The Agency) via email:
"The licensee ( Dana Farber Cancer Institute) reported by telephone on August 23, 2022, that it discovered on August 22, 2022, that it had administered on August 22, 2022, a radiopharmaceutical (10 millicuries of F-18 FDG) as part of a PET/CT diagnostic procedure to a patient that was unknowingly pregnant resulting in an estimated dose to the embryo/fetus of 20 milli-gray (20 millisievert or 2 rem). The estimated dose is inclusive of both the F-18 PET and CT components of the procedure.
"The reporting requirement is 105 CMR 120.594(B), Report and Notification of a Dose to an Embryo/Fetus or Nursing Child, a by no later than next calendar day of the event telephone report.
"The licensee reported that pregnancy screening questions were answered through an interpreter, stating that the patient was not pregnant and that the result of the PET/CT scan showed that the patient was pregnant.
"The licensee reported that the referring physician and the patient have been notified. The licensee reported that at this time (August 23, 2022) there is no expectation of physical/deterministic harm to the fetus from the dose received.
"The licensee reported that a written report will be submitted to the Agency within 15 days of the telephone report in accordance with 105 CMR 120.594(B)(4).
"The Agency considers this event to be open."
Massachusetts Event Number: 20-5109
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: 56092
Rep Org: Mississippi Div of Rad Health
Licensee: The Chemours Company
Region: 4
City: Pass Christian State: MS
County:
License #: MS-409-01
Agreement: Y
Docket:
NRC Notified By: Robert Sims
HQ OPS Officer: Brian P. Smith
Licensee: The Chemours Company
Region: 4
City: Pass Christian State: MS
County:
License #: MS-409-01
Agreement: Y
Docket:
NRC Notified By: Robert Sims
HQ OPS Officer: Brian P. Smith
Notification Date: 09/06/2022
Notification Time: 17:29 [ET]
Event Date: 08/22/2022
Event Time: 12:00 [CDT]
Last Update Date: 09/06/2022
Notification Time: 17:29 [ET]
Event Date: 08/22/2022
Event Time: 12:00 [CDT]
Last Update Date: 09/06/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Pick, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Pick, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - STUCK SHUTTER RESULTS IN UNINTENDED EXPOSURE
The following event was received via e-mail from the Mississippi State Department of Radiological Health:
"On August 22, 2022, the [Radiation Safety Officer] RSO reported to the Mississippi Director of Radiological Health that a shutter was found stuck open during six month surveys. [The gauge is an Ohmart/Vega Model SH-F2-45, Serial Number 2933 CN, with a 100 mCi Cesium 137 source]. On August 31, 2022, source lock out procedures were implemented to allow a crew in the tank to inspect the tank. The gauge was locked out in the unshielded position. A confined entry crew of four workers were exposed for seventy-seven minutes and three workers were exposed for twenty-two minutes. On September 2, 2022 at approximately 1830 [CDT], the licensee RSO contacted the Radioactive Material Director regarding the exposures. On September 6, 2022 at 1247 [CDT], the inspector was notified of the incident, contacted the licensee, and will arrive on site on September 7, 2022. Findings and updates will be reported to the NRC after onsite investigation."
Mississippi Event Number: MS-220003
The following event was received via e-mail from the Mississippi State Department of Radiological Health:
"On August 22, 2022, the [Radiation Safety Officer] RSO reported to the Mississippi Director of Radiological Health that a shutter was found stuck open during six month surveys. [The gauge is an Ohmart/Vega Model SH-F2-45, Serial Number 2933 CN, with a 100 mCi Cesium 137 source]. On August 31, 2022, source lock out procedures were implemented to allow a crew in the tank to inspect the tank. The gauge was locked out in the unshielded position. A confined entry crew of four workers were exposed for seventy-seven minutes and three workers were exposed for twenty-two minutes. On September 2, 2022 at approximately 1830 [CDT], the licensee RSO contacted the Radioactive Material Director regarding the exposures. On September 6, 2022 at 1247 [CDT], the inspector was notified of the incident, contacted the licensee, and will arrive on site on September 7, 2022. Findings and updates will be reported to the NRC after onsite investigation."
Mississippi Event Number: MS-220003