Event Notification Report for March 08, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/07/2023 - 03/08/2023
Hospital
Event Number: 56404
Rep Org: Avera McKennan
Licensee: Avera McKennan
Region: 4
City: Sioux Falls State: SD
County:
License #: 401657101
Agreement: N
Docket:
NRC Notified By: Tracy Hollingshead
HQ OPS Officer: Bill Gott
Licensee: Avera McKennan
Region: 4
City: Sioux Falls State: SD
County:
License #: 401657101
Agreement: N
Docket:
NRC Notified By: Tracy Hollingshead
HQ OPS Officer: Bill Gott
Notification Date: 03/10/2023
Notification Time: 11:30 [ET]
Event Date: 03/08/2023
Event Time: 12:30 [CST]
Last Update Date: 03/10/2023
Notification Time: 11:30 [ET]
Event Date: 03/08/2023
Event Time: 12:30 [CST]
Last Update Date: 03/10/2023
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):
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MEDICAL EVENT - DOSAGE NOT IN ACCORDANCE WITH THE WRITTEN DIRECTIVE
The following information was obtained from the licensee via telephone in accordance with Headquarters Operations Officers Report Guidance:
On March 8, 2023 at 1230 CST, three of nine catheters of a Venezia applicator with 6.8 Ci of Ir-192 were incorrectly mapped to channels in the after loader. This resulted in a dose to the patient that was not in accordance with the written directive. This was discovered on March 9, 2023. The patient and ordering physician were notified.
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 obtained from the licensee via telephone in accordance with Headquarters Operations Officers Report Guidance:
On March 8, 2023 at 1230 CST, three of nine catheters of a Venezia applicator with 6.8 Ci of Ir-192 were incorrectly mapped to channels in the after loader. This resulted in a dose to the patient that was not in accordance with the written directive. This was discovered on March 9, 2023. The patient and ordering physician were notified.
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: 56418
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: Ernest West
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: Ernest West
Notification Date: 03/17/2023
Notification Time: 14:57 [ET]
Event Date: 03/08/2023
Event Time: 22:47 [CDT]
Last Update Date: 04/18/2023
Notification Time: 14:57 [ET]
Event Date: 03/08/2023
Event Time: 22:47 [CDT]
Last Update Date: 04/18/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Nguyen, April (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Nguyen, April (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 4/19/2023
EN Revision Text: AGREEMENT STATE REPORT - LOST PACKAGES
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"The Agency [Illinois Emergency Management Agency] was notified the evening of 3/16/23 by General Electric (GE) Healthcare in Arlington Heights, IL to advise of two radiopharmaceutical packages that were missing in transit. The last known location was the carrier hub in Memphis, TN. The carrier has advised efforts to locate the packages have ceased and both have been declared as lost. These packages do not represent a significant public safety hazard and there are no indications of intentional theft or diversion. TN and TX program officials have been notified as well. Additional details will be provided as they become available. This matter has a 30-day reporting requirement to the NRC [Nuclear Regulatory Commission] with a required call to the NRC Headquarters Operations Officer (HOO). Details on the packages are as follows:
"Package 1:
[The package] shipped 3/8/23 to Doctor's Hospital at Renaissance in Edinburg, TX. [The package] contained (1) 10mL shielded vial of I-123. Package activity at the time of shipment was 14.3 mCi. [The package contains] 0.0002 mCi of activity as of 3/17/2022 at 1500 EDT. The last scan occurred 2247 CDT on 3/8/23. GE Healthcare contacted the customer and confirmed that the package was not received.
"Package 2:
[The package] shipped 3/10/23 to Panhandle Nuclear in Amarillo, TX. [The package] contained (1) 10mL shielded vial of In-111. Package activity at the time of shipment was 3.2 mCi. [The package contains] 0.585 mCi of activity as of 3/17/2022 at 1500 EDT. The last scan occurred 0009 CDT on 3/11/23. GE Healthcare contacted the customer and confirmed that the package was not received."
IL Event Number: IL230007
* * * UPDATE ON 04/18/23 AT 1220 EDT FROM GARY FORSEE TO JOHN RUSSELL * * *
"As of 4/17/2023 the packages remain lost. No additional information has been provided by the carrier. The packages have decayed to background and do not represent a public safety hazard. This report will be updated with any new information but is otherwise considered closed."
Notified R3DO (Orth), NMSS Events Notification, and ILTAB via email.
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
EN Revision Text: AGREEMENT STATE REPORT - LOST PACKAGES
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"The Agency [Illinois Emergency Management Agency] was notified the evening of 3/16/23 by General Electric (GE) Healthcare in Arlington Heights, IL to advise of two radiopharmaceutical packages that were missing in transit. The last known location was the carrier hub in Memphis, TN. The carrier has advised efforts to locate the packages have ceased and both have been declared as lost. These packages do not represent a significant public safety hazard and there are no indications of intentional theft or diversion. TN and TX program officials have been notified as well. Additional details will be provided as they become available. This matter has a 30-day reporting requirement to the NRC [Nuclear Regulatory Commission] with a required call to the NRC Headquarters Operations Officer (HOO). Details on the packages are as follows:
"Package 1:
[The package] shipped 3/8/23 to Doctor's Hospital at Renaissance in Edinburg, TX. [The package] contained (1) 10mL shielded vial of I-123. Package activity at the time of shipment was 14.3 mCi. [The package contains] 0.0002 mCi of activity as of 3/17/2022 at 1500 EDT. The last scan occurred 2247 CDT on 3/8/23. GE Healthcare contacted the customer and confirmed that the package was not received.
"Package 2:
[The package] shipped 3/10/23 to Panhandle Nuclear in Amarillo, TX. [The package] contained (1) 10mL shielded vial of In-111. Package activity at the time of shipment was 3.2 mCi. [The package contains] 0.585 mCi of activity as of 3/17/2022 at 1500 EDT. The last scan occurred 0009 CDT on 3/11/23. GE Healthcare contacted the customer and confirmed that the package was not received."
IL Event Number: IL230007
* * * UPDATE ON 04/18/23 AT 1220 EDT FROM GARY FORSEE TO JOHN RUSSELL * * *
"As of 4/17/2023 the packages remain lost. No additional information has been provided by the carrier. The packages have decayed to background and do not represent a public safety hazard. This report will be updated with any new information but is otherwise considered closed."
Notified R3DO (Orth), NMSS Events Notification, and ILTAB via email.
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: 56398
Rep Org: California Radiation Control Prgm
Licensee: Converse Consultants, Inc. (Redlands)
Region: 4
City: Redlands State: CA
County:
License #: 8057-36
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Thomas Herrity
Licensee: Converse Consultants, Inc. (Redlands)
Region: 4
City: Redlands State: CA
County:
License #: 8057-36
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Thomas Herrity
Notification Date: 03/09/2023
Notification Time: 14:25 [ET]
Event Date: 03/08/2023
Event Time: 10:00 [PST]
Last Update Date: 03/09/2023
Notification Time: 14:25 [ET]
Event Date: 03/08/2023
Event Time: 10:00 [PST]
Last Update Date: 03/09/2023
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 - DAMAGED TROXLER GAUGE
The following was received from the California Department of Public Health, Radiologic Health Branch (RHB) via email:
"On Wednesday, March 8, 2023, at approximately 1000 PST, the Radiation Safety Officer (RSO) of Converse Consultants, Inc. (Redlands), radioactive materials license number 8057-36, contacted the RHB Brea office concerning a Troxler moisture/density gauge (Cs-137 0.296 giga-becquerels (8 millicuries), Am-241 1.48 giga-becquerels (40 millicuries)) that had been damaged when driven over by a vehicle at a construction site in Moreno Valley, CA. The gauge handle was in the shielded position when the gauge was struck and was bent during the incident. The area was cleared until the gauge was surveyed by the RSO and Assistant RSO to assess if the Cs-137 source was still in the lead shielding. The survey by the licensee confirmed the source remained in the shielded position based on exposure rate levels being in the normal range for a shielded source. The locking mechanism on the source rod is not functional. Due to the extent of damage to the gauge, the gauge was then taken to Maurer Technical Services, LLC., radioactive materials license number 6163-30 for leak test analysis and disposition.
"A copy of the incident report from the authorized user of Converse Consultants will be forwarded to the RHB Brea office and will be included as part of this investigation."
California NMED Number: 030823
The following was received from the California Department of Public Health, Radiologic Health Branch (RHB) via email:
"On Wednesday, March 8, 2023, at approximately 1000 PST, the Radiation Safety Officer (RSO) of Converse Consultants, Inc. (Redlands), radioactive materials license number 8057-36, contacted the RHB Brea office concerning a Troxler moisture/density gauge (Cs-137 0.296 giga-becquerels (8 millicuries), Am-241 1.48 giga-becquerels (40 millicuries)) that had been damaged when driven over by a vehicle at a construction site in Moreno Valley, CA. The gauge handle was in the shielded position when the gauge was struck and was bent during the incident. The area was cleared until the gauge was surveyed by the RSO and Assistant RSO to assess if the Cs-137 source was still in the lead shielding. The survey by the licensee confirmed the source remained in the shielded position based on exposure rate levels being in the normal range for a shielded source. The locking mechanism on the source rod is not functional. Due to the extent of damage to the gauge, the gauge was then taken to Maurer Technical Services, LLC., radioactive materials license number 6163-30 for leak test analysis and disposition.
"A copy of the incident report from the authorized user of Converse Consultants will be forwarded to the RHB Brea office and will be included as part of this investigation."
California NMED Number: 030823