Event Notification Report for August 28, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/27/2023 - 08/28/2023
Agreement State
Event Number: 56699
Rep Org: Wisconsin Radiation Protection
Licensee: Aurora Health Care Southern Lakes
Region: 3
City: Mount Pleasant State: WI
County:
License #: 059-1019-01
Agreement: Y
Docket:
NRC Notified By: Kyle Walton
HQ OPS Officer: Karen Cotton-Gross
Licensee: Aurora Health Care Southern Lakes
Region: 3
City: Mount Pleasant State: WI
County:
License #: 059-1019-01
Agreement: Y
Docket:
NRC Notified By: Kyle Walton
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 08/29/2023
Notification Time: 10:45 [ET]
Event Date: 08/28/2023
Event Time: 09:16 [CDT]
Last Update Date: 08/29/2023
Notification Time: 10:45 [ET]
Event Date: 08/28/2023
Event Time: 09:16 [CDT]
Last Update Date: 08/29/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE - MEDICAL UNDERDOSE
The following information was provided by the Wisconsin Radiation Protection (the Department) via email:
"On August 28, 2023, the Department received a notification from the licensee's radiation safety officer about a Y-90 (Yttrium) Therasphere dose that was not delivered as prescribed to the patient. The procedure occurred at 0916 CDT on August 28, 2023. The written directive stated that the dose delivered should be 175 Gray (Gy). The estimated dose delivered to the liver was 31.7 Gy, 18 percent of the prescribed dose. During the administration, it was identified that the spheres appeared to be clumping. The licensee attempted physical agitation of the line, as well as 8 flushes. The licensee decided to terminate the procedure when it was clear they were not administering the dose as desired. A Therasphere representative was on-site for the administration. The patient was notified and a follow-up procedure is scheduled to deliver the remainder of the dose. The Department will follow up with a site visit to investigate the incident."
Wisconsin Event Report ID Number: WI230015
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 Wisconsin Radiation Protection (the Department) via email:
"On August 28, 2023, the Department received a notification from the licensee's radiation safety officer about a Y-90 (Yttrium) Therasphere dose that was not delivered as prescribed to the patient. The procedure occurred at 0916 CDT on August 28, 2023. The written directive stated that the dose delivered should be 175 Gray (Gy). The estimated dose delivered to the liver was 31.7 Gy, 18 percent of the prescribed dose. During the administration, it was identified that the spheres appeared to be clumping. The licensee attempted physical agitation of the line, as well as 8 flushes. The licensee decided to terminate the procedure when it was clear they were not administering the dose as desired. A Therasphere representative was on-site for the administration. The patient was notified and a follow-up procedure is scheduled to deliver the remainder of the dose. The Department will follow up with a site visit to investigate the incident."
Wisconsin Event Report ID Number: WI230015
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: 56700
Rep Org: Florida Bureau of Radiation Control
Licensee: Mineral Development LLC
Region: 1
City: Bartow State: FL
County:
License #: 13-32721-01
Agreement: Y
Docket:
NRC Notified By: David Pieski
HQ OPS Officer: Lawrence Criscione
Licensee: Mineral Development LLC
Region: 1
City: Bartow State: FL
County:
License #: 13-32721-01
Agreement: Y
Docket:
NRC Notified By: David Pieski
HQ OPS Officer: Lawrence Criscione
Notification Date: 08/29/2023
Notification Time: 15:24 [ET]
Event Date: 08/28/2023
Event Time: 10:00 [EDT]
Last Update Date: 08/29/2023
Notification Time: 15:24 [ET]
Event Date: 08/28/2023
Event Time: 10:00 [EDT]
Last Update Date: 08/29/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - RECOVERED LOOSE SOURCE FOR FLOW METER
The following is a summary of information provided by the Florida Bureau of Radiation Control (BRC) via telephone and email:
Mineral Development Safety Officer notified the BRC the morning of 8/28/23, of a 50 mCi [Cs-137] source that had fallen out of a Endress Hauser flow density gamma meter due to vibration. The source was on the ground adjacent to the meter. The area was secured and excluded. Mineral Development has no radiological survey meters onsite and a BRC manager and inspector were sent to investigate and secure the source.
On 8/29/23, a BRC inspector returned to the site and verified that a local representative from Qal-Tek had returned the source to the shielded position within the gamma meter. The meter will remain out of service until its subsequent removal from the piping system.
The BRC verified that Endress Hauser sold the gauge to Mineral Development, but the sale was not reported to the BRC by any party.
Florida Incident Number: FL23-131
The following is a summary of information provided by the Florida Bureau of Radiation Control (BRC) via telephone and email:
Mineral Development Safety Officer notified the BRC the morning of 8/28/23, of a 50 mCi [Cs-137] source that had fallen out of a Endress Hauser flow density gamma meter due to vibration. The source was on the ground adjacent to the meter. The area was secured and excluded. Mineral Development has no radiological survey meters onsite and a BRC manager and inspector were sent to investigate and secure the source.
On 8/29/23, a BRC inspector returned to the site and verified that a local representative from Qal-Tek had returned the source to the shielded position within the gamma meter. The meter will remain out of service until its subsequent removal from the piping system.
The BRC verified that Endress Hauser sold the gauge to Mineral Development, but the sale was not reported to the BRC by any party.
Florida Incident Number: FL23-131