Event Notification Report for March 23, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/22/2023 - 03/23/2023
Agreement State
Event Number: 56412
Rep Org: NJ Rad Prot And Rel Prevention Pgm
Licensee: Hackensack University Medical Ctr
Region: 1
City: Hackensack State: NJ
County:
License #: 450695
Agreement: Y
Docket:
NRC Notified By: Richard Peros
HQ OPS Officer: Bill Gott
Notification Date: 03/15/2023
Notification Time: 13:17 [ET]
Event Date: 03/14/2023
Event Time: 00:00 [EDT]
Last Update Date: 03/16/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Bickett, Brice (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - PATIENT TREATMENT SUSPENDED PRIOR TO COMPLETION
The following information was provided by the New Jersey Department of Environmental Protection (DEP) via email:
"While receiving treatment with an Elekta Leksell Gamma Knife ICON unit, serial number 6135, the patient's treatment had to be suspended. During the administration of the treatment, after the conclusion of a prescribed shot, but before completion of the full treatment, the unit displayed an error that could not be resolved by licensee personnel and required a service technician. The treatment was consequently suspended. The service technician identified a worn sector drive as the cause of the malfunction. The dose administered versus the dose prescribed is still under discussion. The licensee will follow-up with a full report."
NJ Event Report ID number: NJ-23-0001
* * * UPDATE ON 3/16/23 AT 1513 EST FROM RICHARD PEROS TO BILL GOTT * * *
"Additional information has been obtained related to the initial notification provided on 3/15/23.
"The dose administered to the patient was only approximately 2.9 percent of the dose prescribed.
"The prescribed dose was 15 Gy.
"The unit malfunctioned after only 3 of the planned 13 shots was completed.
"14.5589 Gy still needed to be administered out of the 15 Gy when the malfunction occurred.
"This incident therefore does qualify as a medical event as per 10 CFR 35.3045(a)."
Notified R1DO (Bickett) and NMSS Events Notification.
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: 56416
Rep Org: New Mexico Rad Control Program
Licensee: Chino Mines
Region: 4
City: Bayard State: NM
County:
License #: GA 045 47
Agreement: Y
Docket:
NRC Notified By: Carl Sullivan
HQ OPS Officer: Bill Gott
Notification Date: 03/16/2023
Notification Time: 17:04 [ET]
Event Date: 03/15/2023
Event Time: 16:22 [MDT]
Last Update Date: 03/16/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - DENSITY GAUGE SHUTTER FAILURE
The following is a summary of the information provided by the New Mexico Radiation Control Bureau via telephone:
A Berthold Model LB7440 density gauge (serial number 2110) installed in a mine was discovered to have a shutter stuck in the open position while removing the gauge from service. The gauge contains a 20 millicurie Cs-137 source. The licensee installed shielding on the gauge and placed it in a storage container. Radiation surveys around the container are between 0.032 and 0.0525 millirem. An authorized service company is scheduled to repair the gauge on March 27, 2023.