Event Notification Report for October 27, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
10/26/2022 - 10/27/2022

EVENT NUMBERS
56169 56170
Agreement State
Event Number: 56169
Rep Org: Minnesota Department of Health
Licensee: Carris Health LLC
Region: 3
City: Willmar   State: MN
County:
License #: 1207
Agreement: Y
Docket:
NRC Notified By: Brandon Juran
HQ OPS Officer: Lauren Bryson
Notification Date: 10/19/2022
Notification Time: 15:09 [ET]
Event Date: 09/22/2022
Event Time: 00:00 [CDT]
Last Update Date: 10/19/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOST SEED

The following information was provided by the Minnesota Department of Health (MDH) via email:

"The Minnesota Department of Health was notified on 9/27/2022 of a lost localization seed (I-125, 0.188 mCi) that went missing on 6/30/2022. The seed was not identified as missing until 9/22/2022 during an audit. The specimen, with the seed, was transported to pathology and kept with the tissue during the processing of the sample. The pathologist believed the seed was non-radioactive due to the proper paperwork not being present with the seed (the licensee uses radioactive and magnetic seeds). The tissue specimen and seed were disposed of in the biohazard waste stream."

Minnesota Event Number: MN220006

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


Hospital
Event Number: 56170
Rep Org: West Valley Medical Center
Licensee: West Valley Medical Center
Region: 4
City: Caldwell   State: ID
County:
License #: 11-27087-01
Agreement: N
Docket:
NRC Notified By: Peri Steele
HQ OPS Officer: Adam Koziol
Notification Date: 10/19/2022
Notification Time: 20:24 [ET]
Event Date: 11/16/2018
Event Time: 00:00 [MDT]
Last Update Date: 10/19/2022
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
POSSIBLE MEDICAL OVERDOSE

The following is a summary of a phone call with the licensee's Radiation Safety Officer:

During a NRC inspector audit on October 18, 2022, an apparent overdose was identified when records showed a patient received 21.1 millicuries of I-131 for thyroid therapy. The prescribed dose in the file appeared to read 20 microcuries of I-131 vice 20 millicuries. There were no reported adverse effects for the patient.

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.

Page Last Reviewed/Updated Thursday, October 27, 2022