Event Notification Report for September 28, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/27/2022 - 09/28/2022
Hospital
Event Number: 56130
Rep Org: New Haven Hospital
Licensee: New Haven Hospital
Region: 1
City: New Haven State: CT
County: New Haven
License #: 06-00819-03
Agreement: N
Docket:
NRC Notified By: Bill Hinchcliffe
HQ OPS Officer: Adam Koziol
Licensee: New Haven Hospital
Region: 1
City: New Haven State: CT
County: New Haven
License #: 06-00819-03
Agreement: N
Docket:
NRC Notified By: Bill Hinchcliffe
HQ OPS Officer: Adam Koziol
Notification Date: 09/29/2022
Notification Time: 14:54 [ET]
Event Date: 09/28/2022
Event Time: 16:30 [EDT]
Last Update Date: 11/09/2022
Notification Time: 14:54 [ET]
Event Date: 09/28/2022
Event Time: 16:30 [EDT]
Last Update Date: 11/09/2022
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Ambrosini, Josephine (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Ambrosini, Josephine (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MEDICAL EVENT - PATIENT UNDERDOSE
The following information was provided by the licensee via phone:
New Haven Hospital performed stereotactic radiosurgery treatment plan on brain lesions using a gamma knife. Following the procedure, it was determined that up to 6 of the 10 targets could have been missed resulting in up to a 50 percent underdose to the intended targets. There was no indication of unintended damage to neighboring tissues, organs, or structures.
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 phone:
New Haven Hospital performed stereotactic radiosurgery treatment plan on brain lesions using a gamma knife. Following the procedure, it was determined that up to 6 of the 10 targets could have been missed resulting in up to a 50 percent underdose to the intended targets. There was no indication of unintended damage to neighboring tissues, organs, or structures.
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: 56144
Rep Org: Colorado Dept of Health
Licensee: Breckenridge Golf Course
Region: 4
City: Breckenridge State: CO
County:
License #: GL000799
Agreement: Y
Docket:
NRC Notified By: Kathryn Kirk
HQ OPS Officer: Kerby Scales
Licensee: Breckenridge Golf Course
Region: 4
City: Breckenridge State: CO
County:
License #: GL000799
Agreement: Y
Docket:
NRC Notified By: Kathryn Kirk
HQ OPS Officer: Kerby Scales
Notification Date: 10/05/2022
Notification Time: 14:57 [ET]
Event Date: 09/28/2022
Event Time: 00:00 [MDT]
Last Update Date: 10/05/2022
Notification Time: 14:57 [ET]
Event Date: 09/28/2022
Event Time: 00:00 [MDT]
Last Update Date: 10/05/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
AGREEMENT STATE REPORT - LOST EXIT SIGN
The following information was received from the state of Colorado via email:
On 10/5/22, the licensee reported the loss of 2 exit signs.
Manufacturer: Isolite Corporation
Model Number: 2040
Isotope and Activity: H3, 7.5 Curies each
Colorado Event Report Identification Number: C0220032
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 received from the state of Colorado via email:
On 10/5/22, the licensee reported the loss of 2 exit signs.
Manufacturer: Isolite Corporation
Model Number: 2040
Isotope and Activity: H3, 7.5 Curies each
Colorado Event Report Identification Number: C0220032
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: 56156
Rep Org: Minnesota Department of Health
Licensee: Mayo Clinic
Region: 3
City: Rochester State: MN
County:
License #: 1047
Agreement: Y
Docket:
NRC Notified By: Tyler Kruse
HQ OPS Officer: Brian Lin
Licensee: Mayo Clinic
Region: 3
City: Rochester State: MN
County:
License #: 1047
Agreement: Y
Docket:
NRC Notified By: Tyler Kruse
HQ OPS Officer: Brian Lin
Notification Date: 10/10/2022
Notification Time: 14:18 [ET]
Event Date: 09/28/2022
Event Time: 00:00 [CDT]
Last Update Date: 10/19/2022
Notification Time: 14:18 [ET]
Event Date: 09/28/2022
Event Time: 00:00 [CDT]
Last Update Date: 10/19/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 10/19/2022
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL MISADMINSTRATION
The following summary was received from the Minnesota Department of Health via email:
A patient undergoing Lu-177 therapy was administered 110 mCi vice the prescribed 200 mCi. An investigation is in progress by the Minnesota Department of Health.
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.
Minnesota Event ID: MN220005
* * * UPDATE FROM TYLER KRUSE TO DONALD NORWOOD AT 0907 EDT ON 10/17/2022 * * *
The following information was received via email:
"The event date for this event was 09/28/2022. This event was discovered while investigating the event that occurred on 09/27/2022." [That event is recorded as EN56137.]
Notified R3DO (Kunowski) and NMSS Events Notification email group.
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL MISADMINSTRATION
The following summary was received from the Minnesota Department of Health via email:
A patient undergoing Lu-177 therapy was administered 110 mCi vice the prescribed 200 mCi. An investigation is in progress by the Minnesota Department of Health.
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.
Minnesota Event ID: MN220005
* * * UPDATE FROM TYLER KRUSE TO DONALD NORWOOD AT 0907 EDT ON 10/17/2022 * * *
The following information was received via email:
"The event date for this event was 09/28/2022. This event was discovered while investigating the event that occurred on 09/27/2022." [That event is recorded as EN56137.]
Notified R3DO (Kunowski) and NMSS Events Notification email group.
Agreement State
Event Number: 56250
Rep Org: Ohio Bureau of Radiation Protection
Licensee: NDC Technologies, Inc.
Region: 3
City: Dayton State: OH
County:
License #: 03214580002
Agreement: Y
Docket:
NRC Notified By: Michael Snee
HQ OPS Officer: Ernest West
Licensee: NDC Technologies, Inc.
Region: 3
City: Dayton State: OH
County:
License #: 03214580002
Agreement: Y
Docket:
NRC Notified By: Michael Snee
HQ OPS Officer: Ernest West
Notification Date: 12/01/2022
Notification Time: 13:51 [ET]
Event Date: 09/28/2022
Event Time: 00:00 [EST]
Last Update Date: 12/01/2022
Notification Time: 13:51 [ET]
Event Date: 09/28/2022
Event Time: 00:00 [EST]
Last Update Date: 12/01/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Peterson, Hironori (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Peterson, Hironori (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - SOURCE INADVERTENTLY SHIPPED
The following information was provided by the Ohio Department of Health via email:
"[The] licensee (NDC Technologies, Inc.) inadvertently shipped a 150 mCi Am-241 source to a customer in Germany. Only the electronic portion of the gauge should have been shipped to that customer. The source was [intended] to be shipped separately to a separate licensed facility in Germany. The source was not handled at the facility in Germany and was immediately sent back. The source has arrived at the NDC facility in Dayton."
Ohio Reference Number: OH220012
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 Ohio Department of Health via email:
"[The] licensee (NDC Technologies, Inc.) inadvertently shipped a 150 mCi Am-241 source to a customer in Germany. Only the electronic portion of the gauge should have been shipped to that customer. The source was [intended] to be shipped separately to a separate licensed facility in Germany. The source was not handled at the facility in Germany and was immediately sent back. The source has arrived at the NDC facility in Dayton."
Ohio Reference Number: OH220012
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