Event Notification Report for September 21, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/20/2023 - 09/21/2023
Hospital
Event Number: 56758
Rep Org: Stamford Hospital
Licensee: Stamford Hospital
Region: 1
City: Stamford State: CT
County:
License #: 06-06697-02
Agreement: N
Docket:
NRC Notified By: Peter Mas
HQ OPS Officer: John Russell
Licensee: Stamford Hospital
Region: 1
City: Stamford State: CT
County:
License #: 06-06697-02
Agreement: N
Docket:
NRC Notified By: Peter Mas
HQ OPS Officer: John Russell
Notification Date: 09/26/2023
Notification Time: 15:35 [ET]
Event Date: 09/21/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/26/2023
Notification Time: 15:35 [ET]
Event Date: 09/21/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/26/2023
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(3) - Dose To Other Site > Specified Limits
10 CFR Section:
35.3045(a)(3) - Dose To Other Site > Specified Limits
Person (Organization):
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MEDICAL EVENT - DOSE TO UNINTENDED PART OF ORGAN
The following information is a summary of the information provided by the licensee via telephone:
On September 21, 2023, a female patient received the first of three scheduled doses using a vaginal cylinder containing 5 curies of Iridium 192. The cylinder shifted inadvertently during the administration by about 3.5 centimeters outward causing the dose to the intended site to be different than the intended dose. The patient was informed.
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 is a summary of the information provided by the licensee via telephone:
On September 21, 2023, a female patient received the first of three scheduled doses using a vaginal cylinder containing 5 curies of Iridium 192. The cylinder shifted inadvertently during the administration by about 3.5 centimeters outward causing the dose to the intended site to be different than the intended dose. The patient was informed.
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: 56775
Rep Org: OR Dept of Health Rad Protection
Licensee: Oregon Health & Sciences University
Region: 4
City: Portland State: OR
County:
License #: ORE-90013
Agreement: Y
Docket:
NRC Notified By: Michelle Martin
HQ OPS Officer: Karen Cotton-Gross
Licensee: Oregon Health & Sciences University
Region: 4
City: Portland State: OR
County:
License #: ORE-90013
Agreement: Y
Docket:
NRC Notified By: Michelle Martin
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 10/03/2023
Notification Time: 16:42 [ET]
Event Date: 09/21/2023
Event Time: 10:00 [PDT]
Last Update Date: 10/05/2023
Notification Time: 16:42 [ET]
Event Date: 09/21/2023
Event Time: 10:00 [PDT]
Last Update Date: 10/05/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following information was provided by the Oregon Department of Health Radiation Protection via email:
"At 1000 PDT on September 21, 2023, during an administration of a split-dose of Y-90 [yttrium] SirSpheres to the liver, the first dose was not completely delivered to the patient. The second dose, same lobe but a different site, was delivered completely. (First prescribed dose: 7.2mCi; First delivered dose: 5.614 mCi)
"The physician does not believe additional treatment will be needed but the case will be discussed by the licensee in a follow-up conference. The senior radiologist believes there was a `clump of spheres' remaining at the hub of the syringe for the first dose, resulting in under-dosing the patient by more than 20 percent.
"Corrective action is still to be determined."
Oregon Event Report Number: 23-0051
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 Oregon Department of Health Radiation Protection via email:
"At 1000 PDT on September 21, 2023, during an administration of a split-dose of Y-90 [yttrium] SirSpheres to the liver, the first dose was not completely delivered to the patient. The second dose, same lobe but a different site, was delivered completely. (First prescribed dose: 7.2mCi; First delivered dose: 5.614 mCi)
"The physician does not believe additional treatment will be needed but the case will be discussed by the licensee in a follow-up conference. The senior radiologist believes there was a `clump of spheres' remaining at the hub of the syringe for the first dose, resulting in under-dosing the patient by more than 20 percent.
"Corrective action is still to be determined."
Oregon Event Report Number: 23-0051
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: 56956
Rep Org: Georgia Radioactive Material Pgm
Licensee: Shasta Beverages
Region: 1
City: Gainesville State: GA
County:
License #: GA 1756-2017-GL-1
Agreement: Y
Docket:
NRC Notified By: Elijah Holloway
HQ OPS Officer: Bill Gott
Licensee: Shasta Beverages
Region: 1
City: Gainesville State: GA
County:
License #: GA 1756-2017-GL-1
Agreement: Y
Docket:
NRC Notified By: Elijah Holloway
HQ OPS Officer: Bill Gott
Notification Date: 02/09/2024
Notification Time: 10:55 [ET]
Event Date: 09/21/2023
Event Time: 00:00 [EST]
Last Update Date: 03/06/2024
Notification Time: 10:55 [ET]
Event Date: 09/21/2023
Event Time: 00:00 [EST]
Last Update Date: 03/06/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
EN Revision Imported Date: 3/7/2024
EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCE
The following information was received from the Georgia Radioactive Material Program via email:
"On or about 9/21/23, a Filtec model FT-50C, containing 100 mCi of Am-241, was mistakenly placed into a scrap dumpster on-site by an employee of Shasta Beverages, Inc. The gauge was taken off-site in the scrap dumpster by a scrap collection company. The scrap company is unsure of which of two locations the dumpster was taken, a recycling facility or a scrap yard. This report serves as initial notification and will be followed up with additional information."
Georgia Incident Number: 78
* * * UPDATE ON 3/6/24 AT 1340 EST FROM ELIJAH HOLLOWAY TO ADAM KOZIOL * * *
The Filtec unit was located at a scrap yard and returned to the licensee. The licensee has contacted the manufacturer to verify the device serial number and to perform a source leak test. The device and source appear intact.
Notified R1DO (Arner), NMSS Events (email), and ILTAB (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 SOURCE
The following information was received from the Georgia Radioactive Material Program via email:
"On or about 9/21/23, a Filtec model FT-50C, containing 100 mCi of Am-241, was mistakenly placed into a scrap dumpster on-site by an employee of Shasta Beverages, Inc. The gauge was taken off-site in the scrap dumpster by a scrap collection company. The scrap company is unsure of which of two locations the dumpster was taken, a recycling facility or a scrap yard. This report serves as initial notification and will be followed up with additional information."
Georgia Incident Number: 78
* * * UPDATE ON 3/6/24 AT 1340 EST FROM ELIJAH HOLLOWAY TO ADAM KOZIOL * * *
The Filtec unit was located at a scrap yard and returned to the licensee. The licensee has contacted the manufacturer to verify the device serial number and to perform a source leak test. The device and source appear intact.
Notified R1DO (Arner), NMSS Events (email), and ILTAB (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