Event Notification Report for June 29, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/28/2023 - 06/29/2023
Hospital
Event Number: 56601
Rep Org: Saint Louis University
Licensee: Saint Louis University
Region: 3
City: St. Louis State: MO
County:
License #: 24-00196-07
Agreement: N
Docket:
NRC Notified By: Kevin Ferguson
HQ OPS Officer: Eric Simpson
Licensee: Saint Louis University
Region: 3
City: St. Louis State: MO
County:
License #: 24-00196-07
Agreement: N
Docket:
NRC Notified By: Kevin Ferguson
HQ OPS Officer: Eric Simpson
Notification Date: 06/30/2023
Notification Time: 12:15 [ET]
Event Date: 06/29/2023
Event Time: 12:01 [CDT]
Last Update Date: 06/30/2023
Notification Time: 12:15 [ET]
Event Date: 06/29/2023
Event Time: 12:01 [CDT]
Last Update Date: 06/30/2023
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):
Orlikowski, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Orlikowski, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MEDICAL EVENT - PATIENT UNDERDOSE
The following information was provided by the licensee via phone and followed up with an email:
"Yesterday, June 29, 2023, from 1201 to 1314 CDT, a Therasphere procedure was performed on a patient. The prescribed dose was for 14.58 mCi of Yttrium-90 (Y-90) to the left lobe of the liver. The authorized user (AU) stated that everything seemed to go normally other than they remembered afterwards a little more resistance than usual while performing the injection. The patient was sent for imaging and it was discovered shortly after 1500 that there was no dose in the patient. This was investigated, and the dose was found to be in the tubing. It is believed that the radioactive particles got clogged within the catheter. The AU stated that the catheter used was a model Trinav 120 cm length catheter, which is a special catheter with anti-reflux basket to prevent reflux and specially designed for Y-90 delivery.
"The AU stated that they would inform the patient of the medical event on the morning of June 30, 2023 (today).
"Additional details will be provided in the 15-day written report."
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 and followed up with an email:
"Yesterday, June 29, 2023, from 1201 to 1314 CDT, a Therasphere procedure was performed on a patient. The prescribed dose was for 14.58 mCi of Yttrium-90 (Y-90) to the left lobe of the liver. The authorized user (AU) stated that everything seemed to go normally other than they remembered afterwards a little more resistance than usual while performing the injection. The patient was sent for imaging and it was discovered shortly after 1500 that there was no dose in the patient. This was investigated, and the dose was found to be in the tubing. It is believed that the radioactive particles got clogged within the catheter. The AU stated that the catheter used was a model Trinav 120 cm length catheter, which is a special catheter with anti-reflux basket to prevent reflux and specially designed for Y-90 delivery.
"The AU stated that they would inform the patient of the medical event on the morning of June 30, 2023 (today).
"Additional details will be provided in the 15-day written report."
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: 56599
Rep Org: Arizona Dept of Health Services
Licensee: Banner University Medical Center
Region: 4
City: Phoenix State: AZ
County:
License #: 07-478
Agreement: Y
Docket:
NRC Notified By: Brian D. Goretzki
HQ OPS Officer: Karen Cotton-Gross
Licensee: Banner University Medical Center
Region: 4
City: Phoenix State: AZ
County:
License #: 07-478
Agreement: Y
Docket:
NRC Notified By: Brian D. Goretzki
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 06/30/2023
Notification Time: 00:33 [ET]
Event Date: 06/29/2023
Event Time: 00:00 [MST]
Last Update Date: 06/30/2023
Notification Time: 00:33 [ET]
Event Date: 06/29/2023
Event Time: 00:00 [MST]
Last Update Date: 06/30/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
O'Keefe, Neil (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
O'Keefe, Neil (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION
The following information was provided by the Arizona Department of Health Services (The Department) via email:
"The Department received notification from the licensee about a medical event involving I-131. On June 29, 2023, two patients were scheduled to receive I-131 doses of 75 and 100 millicuries (mCi) each. When the certified nuclear medicine technologist (CNMT) was preparing the first dose for the patient (75 mCi), the CNMT assayed the wrong dose but with the correct paperwork.
"The authorized user was present for the administration and gave the patient a 100 mCi dose of I-131 when the prescribed dose was for 75 mCi. The licensee discovered the mistake prior to giving the second patient (prescribed 100 mCi) the incorrect dose of 75 mCi. The Department has requested additional information and continues to investigate the event."
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 Arizona Department of Health Services (The Department) via email:
"The Department received notification from the licensee about a medical event involving I-131. On June 29, 2023, two patients were scheduled to receive I-131 doses of 75 and 100 millicuries (mCi) each. When the certified nuclear medicine technologist (CNMT) was preparing the first dose for the patient (75 mCi), the CNMT assayed the wrong dose but with the correct paperwork.
"The authorized user was present for the administration and gave the patient a 100 mCi dose of I-131 when the prescribed dose was for 75 mCi. The licensee discovered the mistake prior to giving the second patient (prescribed 100 mCi) the incorrect dose of 75 mCi. The Department has requested additional information and continues to investigate the event."
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.
Power Reactor
Event Number: 56598
Facility: Grand Gulf
Region: 4 State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Jeff Hardy
HQ OPS Officer: Ernest West
Region: 4 State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Jeff Hardy
HQ OPS Officer: Ernest West
Notification Date: 06/29/2023
Notification Time: 15:41 [ET]
Event Date: 06/29/2023
Event Time: 08:07 [CDT]
Last Update Date: 06/29/2023
Notification Time: 15:41 [ET]
Event Date: 06/29/2023
Event Time: 08:07 [CDT]
Last Update Date: 06/29/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
O'Keefe, Neil (R4DO)
FFD Group, (EMAIL)
O'Keefe, Neil (R4DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 98 | Power Operation | 98 | Power Operation |
FITNESS-FOR-DUTY REPORT
The following information was provided by the licensee via email:
"A non-licensed supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
"The NRC Resident Inspector has been notified."
The following information was provided by the licensee via email:
"A non-licensed supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
"The NRC Resident Inspector has been notified."
Agreement State
Event Number: 56611
Rep Org: Ohio Bureau of Radiation Protection
Licensee: Geotechnical Consultants, Inc
Region: 3
City: Westerville State: OH
County:
License #: 31210250023
Agreement: Y
Docket:
NRC Notified By: Stephen James
HQ OPS Officer: Adam Koziol
Licensee: Geotechnical Consultants, Inc
Region: 3
City: Westerville State: OH
County:
License #: 31210250023
Agreement: Y
Docket:
NRC Notified By: Stephen James
HQ OPS Officer: Adam Koziol
Notification Date: 07/07/2023
Notification Time: 09:43 [ET]
Event Date: 06/29/2023
Event Time: 00:00 [EDT]
Last Update Date: 07/07/2023
Notification Time: 09:43 [ET]
Event Date: 06/29/2023
Event Time: 00:00 [EDT]
Last Update Date: 07/07/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
McCraw, Aaron (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
McCraw, Aaron (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - LOST AND RECOVERED GAUGE
The following information was provided by the Ohio Department of Health (ODH) via email:
"At approximately 1100 EDT on 6/29/23, ODH received notification from an Ohio radioactive materials licensee that a portable device containing radioactive sources had been lost. The device is a Troxler Model 3430 portable moisture/density gauge containing an 8 millicurie Cesium-137 source and a 40 millicurie Americium-241 source. The device had mistakenly been left on the tailgate of the technician's pickup truck when he left a jobsite to go to another work location. When the driver was stopped at an intersection, he saw in his rearview mirror that
the tailgate was open and stopped to verify the contents of the truck. At that point, he realized the gauge was missing. The technician had travelled approximately 13 miles before discovering that the device had been lost.
"The gauge was recovered later that same day (6/29/23) with no apparent damage."
Ohio Incident Number: OH230007
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 (ODH) via email:
"At approximately 1100 EDT on 6/29/23, ODH received notification from an Ohio radioactive materials licensee that a portable device containing radioactive sources had been lost. The device is a Troxler Model 3430 portable moisture/density gauge containing an 8 millicurie Cesium-137 source and a 40 millicurie Americium-241 source. The device had mistakenly been left on the tailgate of the technician's pickup truck when he left a jobsite to go to another work location. When the driver was stopped at an intersection, he saw in his rearview mirror that
the tailgate was open and stopped to verify the contents of the truck. At that point, he realized the gauge was missing. The technician had travelled approximately 13 miles before discovering that the device had been lost.
"The gauge was recovered later that same day (6/29/23) with no apparent damage."
Ohio Incident Number: OH230007
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