Event Notification Report for December 28, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/27/2022 - 12/28/2022
Agreement State
Event Number: 57084
Rep Org: PA Bureau of Radiation Protection
Licensee: University of Pennsylvania
Region: 1
City: Philadelphia State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Adam Koziol
Licensee: University of Pennsylvania
Region: 1
City: Philadelphia State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Adam Koziol
Notification Date: 04/22/2024
Notification Time: 13:44 [ET]
Event Date: 12/28/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/23/2024
Notification Time: 13:44 [ET]
Event Date: 12/28/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/23/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Werkheiser, Dave (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Werkheiser, Dave (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:
"On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045.
"On April 19, 2024, the licensee discovered a medical event from December 28, 2022. A patient received a diagnostic scan that was performed using 1 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensee's system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient.
"At this time, no other information is available. The Department will update this event as soon as more information is provided."
* * * RETRACTION ON 4/23/24 AT 0740 EDT FROM JOHN CHIPPO TO BILL GOTT * * *
The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:
"The Department wishes to retract this event as it does not meet the qualifications for reporting."
Notified R1DO (Werkheiser) and NMSS Events Notification via email.
PA Event Number: PA240008
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 Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:
"On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045.
"On April 19, 2024, the licensee discovered a medical event from December 28, 2022. A patient received a diagnostic scan that was performed using 1 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensee's system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient.
"At this time, no other information is available. The Department will update this event as soon as more information is provided."
* * * RETRACTION ON 4/23/24 AT 0740 EDT FROM JOHN CHIPPO TO BILL GOTT * * *
The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:
"The Department wishes to retract this event as it does not meet the qualifications for reporting."
Notified R1DO (Werkheiser) and NMSS Events Notification via email.
PA Event Number: PA240008
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.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State
Event Number: 56289
Rep Org: Texas Dept of State Health Services
Licensee: EXXON MOBIL CORPORATION
Region: 4
City: Beaumont State: TX
County:
License #: L 02316
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Ian Howard
Licensee: EXXON MOBIL CORPORATION
Region: 4
City: Beaumont State: TX
County:
License #: L 02316
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Ian Howard
Notification Date: 12/29/2022
Notification Time: 16:35 [ET]
Event Date: 12/28/2022
Event Time: 00:00 [CST]
Last Update Date: 12/30/2022
Notification Time: 16:35 [ET]
Event Date: 12/28/2022
Event Time: 00:00 [CST]
Last Update Date: 12/30/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - POTENTIALLY DAMAGED GAUGE
The following information was provided by the Texas Department of State Health Services (the Agency) via email:
"On December 29, 2022, the Agency was notified by the licensee's consultant that a fire had occurred at the licensee's location. The fire was near two Vega America SHD gauges both containing 120 millicurie (original activity) cesium - 137 sources. The licensee has not been able to determine if the gauges were affected by the fire as of this report. There is a concern that the fire could reflash, so the licensee is being cautious about approaching the gauge. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident No: 9977
* * * RETRACTION ON 12/30/22 AT 1325 FROM ART TUCKER TO LAUREN BRYSON * * *
"On December 30, 2022, the licensee notified the Agency that they were able to inspect the gauges and neither gauge was affected by the fire."
Notified R4DO (Gepford) and NMSS Events Notification via email
The following information was provided by the Texas Department of State Health Services (the Agency) via email:
"On December 29, 2022, the Agency was notified by the licensee's consultant that a fire had occurred at the licensee's location. The fire was near two Vega America SHD gauges both containing 120 millicurie (original activity) cesium - 137 sources. The licensee has not been able to determine if the gauges were affected by the fire as of this report. There is a concern that the fire could reflash, so the licensee is being cautious about approaching the gauge. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident No: 9977
* * * RETRACTION ON 12/30/22 AT 1325 FROM ART TUCKER TO LAUREN BRYSON * * *
"On December 30, 2022, the licensee notified the Agency that they were able to inspect the gauges and neither gauge was affected by the fire."
Notified R4DO (Gepford) and NMSS Events Notification via email