Event Notification Report for December 07, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/06/2023 - 12/07/2023
Agreement State
Event Number: 56881
Rep Org: Georgia Radioactive Material Pgm
Licensee: Wellstar Kennestone Hospital
Region: 2
City: Marietta State: GA
County:
License #: GA 328-1
Agreement: Y
Docket:
NRC Notified By: Kaamilya Najeeullah
HQ OPS Officer: Karen Cotton-Gross
Licensee: Wellstar Kennestone Hospital
Region: 2
City: Marietta State: GA
County:
License #: GA 328-1
Agreement: Y
Docket:
NRC Notified By: Kaamilya Najeeullah
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 12/08/2023
Notification Time: 16:01 [ET]
Event Date: 12/07/2023
Event Time: 00:00 [EST]
Last Update Date: 12/15/2023
Notification Time: 16:01 [ET]
Event Date: 12/07/2023
Event Time: 00:00 [EST]
Last Update Date: 12/15/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 12/18/2023
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL MISADMINSTRATION
The following information is a synopsis of information provided by the Georgia Radioactive Materials Program via email:
The State received a call from the licensee's radiation safety officer on December 7, 2023, stating that a patient, who was scheduled for a high-dose rate (HDR) Ir-192 procedure, received the wrong dose. As of December 8, 2023, the state has not received any additional information. The state will provide updated information once it is provided.
Manufacturer: Nucletron Flexitron
Model: 136149A02
Georgia Incident Number: 73
* * * UPDATE ON 12/15/23 AT 1234 EST FROM KAAMILYA NAJEEULLAH TO THOMAS HERRITY * * *
The following information is a synopsis of information provided by the Georgia Radioactive Materials Program via email:
The official written report from Wellstar Kennestone Hospital, Georgia License GA 328-1, was received from the Radiation Safety Officer (RSO), on December 15, 2023. The report includes details of the misadministration - human error, and the corrective actions the licensee has instituted to prevent recurrence. The patient was underdosed by 2 percent. The prescribing physician was notified and choose not inform the patient of this incident. No adverse effects to the patient are anticipated.
Notified R1DO(Gray) and NMSS Events Notification via email.
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.
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL MISADMINSTRATION
The following information is a synopsis of information provided by the Georgia Radioactive Materials Program via email:
The State received a call from the licensee's radiation safety officer on December 7, 2023, stating that a patient, who was scheduled for a high-dose rate (HDR) Ir-192 procedure, received the wrong dose. As of December 8, 2023, the state has not received any additional information. The state will provide updated information once it is provided.
Manufacturer: Nucletron Flexitron
Model: 136149A02
Georgia Incident Number: 73
* * * UPDATE ON 12/15/23 AT 1234 EST FROM KAAMILYA NAJEEULLAH TO THOMAS HERRITY * * *
The following information is a synopsis of information provided by the Georgia Radioactive Materials Program via email:
The official written report from Wellstar Kennestone Hospital, Georgia License GA 328-1, was received from the Radiation Safety Officer (RSO), on December 15, 2023. The report includes details of the misadministration - human error, and the corrective actions the licensee has instituted to prevent recurrence. The patient was underdosed by 2 percent. The prescribing physician was notified and choose not inform the patient of this incident. No adverse effects to the patient are anticipated.
Notified R1DO(Gray) and NMSS Events Notification via email.
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: 56880
Rep Org: Texas Dept of State Health Services
Licensee: U of Texas MD Anderson Cancer Ctr
Region: 4
City: Houston State: TX
County:
License #: L00466
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Ernest West
Licensee: U of Texas MD Anderson Cancer Ctr
Region: 4
City: Houston State: TX
County:
License #: L00466
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Ernest West
Notification Date: 12/07/2023
Notification Time: 14:36 [ET]
Event Date: 12/07/2023
Event Time: 00:00 [CST]
Last Update Date: 12/09/2023
Notification Time: 14:36 [ET]
Event Date: 12/07/2023
Event Time: 00:00 [CST]
Last Update Date: 12/09/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE - SOURCE STUCK IN UNSHIELDED POSITION
The following information was provided by the Texas Department of State Health Services (the Department) via email:
"On December 7, 2023, the Department was notified by a Texas licensee's radiation safety officer (RSO) that while testing an MDS Nordion, Model Eldorado 8, teletherapy unit, the 1,817 curie cobalt-60 source became stuck in the unshielded position. The RSO stated that the room was isolated and dose rates taken outside the room did not create an exposure risk to any individual. The RSO stated that a service contractor would likely repair the unit on December 9, 2023. Access to the room was posted to prevent inadvertent entry into the room. An update will be provided when the source is returned to the shielded position and then further information will be provided per SA-300."
Texas Incident Number: I-10070
NMED Number: TX230056
* * * UPDATE ON 12/9/23 AT 1137 EST FROM RANDELL REDD TO KAREN COTTON * * *
"On December 9, 2023, the Department was notified that the cobalt-60 source had been returned to the shielded position by the licensed servicing company. The technician who returned the source received around 0.3 millirem. The source activity is likely around 1,000 curies and not 1,817 curies, as originally reported. The Department will wait for the licensee and service company reports for information regarding the cause of the incident and report this to NMED per SA-300."
Notified R4DO (Dixon) and NMSS Events Notification via email.
The following information was provided by the Texas Department of State Health Services (the Department) via email:
"On December 7, 2023, the Department was notified by a Texas licensee's radiation safety officer (RSO) that while testing an MDS Nordion, Model Eldorado 8, teletherapy unit, the 1,817 curie cobalt-60 source became stuck in the unshielded position. The RSO stated that the room was isolated and dose rates taken outside the room did not create an exposure risk to any individual. The RSO stated that a service contractor would likely repair the unit on December 9, 2023. Access to the room was posted to prevent inadvertent entry into the room. An update will be provided when the source is returned to the shielded position and then further information will be provided per SA-300."
Texas Incident Number: I-10070
NMED Number: TX230056
* * * UPDATE ON 12/9/23 AT 1137 EST FROM RANDELL REDD TO KAREN COTTON * * *
"On December 9, 2023, the Department was notified that the cobalt-60 source had been returned to the shielded position by the licensed servicing company. The technician who returned the source received around 0.3 millirem. The source activity is likely around 1,000 curies and not 1,817 curies, as originally reported. The Department will wait for the licensee and service company reports for information regarding the cause of the incident and report this to NMED per SA-300."
Notified R4DO (Dixon) and NMSS Events Notification via email.
Agreement State
Event Number: 56900
Rep Org: New Mexico Rad Control Program
Licensee: Pajarito Scientific Corporation
Region: 4
City: Santa Fe State: NM
County:
License #: CS161-51
Agreement: Y
Docket:
NRC Notified By: Carl Sullivan
HQ OPS Officer: Brian P. Smith
Licensee: Pajarito Scientific Corporation
Region: 4
City: Santa Fe State: NM
County:
License #: CS161-51
Agreement: Y
Docket:
NRC Notified By: Carl Sullivan
HQ OPS Officer: Brian P. Smith
Notification Date: 12/19/2023
Notification Time: 18:40 [ET]
Event Date: 12/07/2023
Event Time: 00:00 [MST]
Last Update Date: 12/19/2023
Notification Time: 18:40 [ET]
Event Date: 12/07/2023
Event Time: 00:00 [MST]
Last Update Date: 12/19/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Taylor, Nick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSNS (Mexico), - (EMAIL)
Taylor, Nick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSNS (Mexico), - (EMAIL)
AGREEMENT STATE REPORT - LOST SOURCE
The following summary of events was received via phone call and email from the New Mexico Environment Department, Radiation Control Bureau (the Bureau):
The licensee reported a lost source to the Bureau on December 7th, 2023. The source was described as a mixed gamma button source S/N 64820-570, 25.4 mm diameter, 1/8 inch thickness, containing multiple isotopes of low activity. The isotope with the highest present day activity was Am-241 with an activity of 0.253 microcuries. All of the other isotopes had a negligible activity by the Bureau's reporting criteria. The source was shipped by the licensee and considered lost on December 7th after receiving an email from the common carrier that they were not able to locate the shipment. There is no evidence that any individual was potentially overexposed as a result of the lost source.
New Mexico Incident #: N/A
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 summary of events was received via phone call and email from the New Mexico Environment Department, Radiation Control Bureau (the Bureau):
The licensee reported a lost source to the Bureau on December 7th, 2023. The source was described as a mixed gamma button source S/N 64820-570, 25.4 mm diameter, 1/8 inch thickness, containing multiple isotopes of low activity. The isotope with the highest present day activity was Am-241 with an activity of 0.253 microcuries. All of the other isotopes had a negligible activity by the Bureau's reporting criteria. The source was shipped by the licensee and considered lost on December 7th after receiving an email from the common carrier that they were not able to locate the shipment. There is no evidence that any individual was potentially overexposed as a result of the lost source.
New Mexico Incident #: N/A
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