U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
08/05/2003 - 08/06/2003
** EVENT NUMBERS **
40042 40047
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|General Information or Other |Event Number: 40042 |
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| REP ORG: ILLINOIS DEPT OF NUCLEAR SAFETY |NOTIFICATION DATE: 07/31/2003|
|LICENSEE: RUSH COPLEY MEDICAL CENTER |NOTIFICATION TIME: 17:50[EDT]|
| CITY: AURORA REGION: 3 |EVENT DATE: 07/28/2003|
| COUNTY: STATE: IL |EVENT TIME: [CDT]|
|LICENSE#: IL-01207-01 AGREEMENT: Y |LAST UPDATE DATE: 08/01/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BRUCE BURGESS R3 |
| |DANIEL GILLEN NMSS |
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| NRC NOTIFIED BY: JOE KLINGER | |
| HQ OPS OFFICER: HOWIE CROUCH | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT - MEDICAL EVENT |
| |
| The following information was received via e-mail from the Illinois |
| Department of Nuclear Safety: |
| |
| "Abstract: |
| |
| "The agency [Illinois Department of Nuclear Safety] received a call July 29, |
| 2003 from a nuclear medicine technician, at Rush Copley Medical Center in |
| Aurora, IL [deleted]. She reported that a patient who was to receive a 4 |
| milliCi unit dose of Tl-201 [Thallium-201] for a heart test instead received |
| a 4 milliCi unit dose of I-131 [Iodine-131] on July 28, 2003. |
| |
| "Circumstances surrounding the event, as reported by the technician, |
| indicate that both the exterior lead container and syringe were labeled as |
| being Tl-201. Although the injection occurred the previous day it was not |
| determined that I-131 was involved until after the gamma cameras used for |
| patient imaging were checked a second time on the morning of July 29th. |
| Service engineers had been called to the site both days to inspect the |
| cameras after both failed attempts to image the patient. The cause became |
| evident when a gamma camera flood source that had been made from what was |
| thought to be the remaining Tl-201 material in the syringe from 7/29/2003 |
| showed peaks consistent with I-131. The assayed amount from Monday's |
| records showed the dose to be within the expected range for a typical 4 |
| milliCi Tl-201 diagnostic doses and as such, was considered to be normal. |
| The technician indicated that the patient involved had been contacted by the |
| referring physician, the onsite oncologists, the hospital Administrator and |
| lawyer and was informed as to what had happened. The hospital has arranged |
| to perform routine blood analysis throughout the year to monitor any changes |
| in thyroid activity. |
| |
| "The RSO [Radiation Safety Officer] and oncologist at the facility, |
| [deleted], were then contacted by the Agency. He indicated that it is very |
| unlikely that any changes will be noted in the patient. He reports that the |
| dose administered, is only slightly larger than that typically ordered for |
| whole body scans using I-131. Regardless, they have offered to provide |
| routine blood testing of the patient throughout the year for T3, T4 and T7 |
| thyroid hormones levels as part of a follow up evaluation. |
| |
| "A call was then made to the Medi Physics/Amersham Health, [deleted] Wood |
| Dale pharmacy facility where the doses had been prepared the previous |
| Friday. [Deleted], Corporate RSO indicated that they were in the process of |
| determining what had occurred but it appeared that when prescriptions and |
| labels were taken from the computer system a 4 milliCi Tl-201 prescription |
| was mistakenly put in with 4 other prescriptions for 4 milliCi unit doses of |
| I-131 to be filled. Subsequently, the Tl-201 request was mistakenly filled |
| as an I-131 prescription. The difference in nuclides was not noted by the |
| pharmacist when the pre-generated Tl-201 labels were applied to the syringe |
| and lead container which now held I-131. |
| |
| "The Agency sent an investigator to the medical center on the morning or |
| July 30 to observe the labeling on the container and syringe, receipt |
| records, gamma camera QA tests and to verify by gamma spectrum analysis the |
| presence of I-131 as well as to conduct preliminary interviews to obtain |
| additional facts. The investigation then moved on to the pharmacy to |
| continue their review of the event. Based on those visits, the information |
| obtained largely confirmed the preliminary notification. The Agency is |
| continuing its investigation of the matter and is expecting reports to be |
| filed by both parties according to regulatory requirements. |
| |
| "Preliminary estimates of EDE to the whole body of 355 Rem and 11,672 Rad to |
| the thyroid based on ICRP 53 modeling assuming 55% uptake and standard man |
| conditions has been calculated. Similar preliminary estimates based on the |
| package insert assuming 25% uptake resulted in 1,628 Rads and 5,328 Rads |
| respectively. The two estimates vary widely because of unknown factors |
| associated with the patient's condition. NRC Operations Center was notified |
| of the event at 17[50] on 31 July 2003 and assigned Event Number 40042." |
| |
| *** UPDATED AT 1705 EDT ON 8/1/03 FROM KLINGER TO CROUCH *** |
| |
| Last paragraph of above report was amended to read as follows: |
| |
| "Preliminary estimates of dose to the thyroid range from 5,300 Rads to |
| 11,700 Rads. The two estimates vary widely because of unknown factors |
| associated with the patient's condition. NRC Operations Center was notified |
| of the event at 1750 E.S.T on 31 July 2003 and assigned Event Number |
| 40042." |
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|Other Nuclear Material |Event Number: 40047 |
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| REP ORG: FROEHLING &ROBERTSON INC |NOTIFICATION DATE: 08/05/2003|
|LICENSEE: FROEHLING &ROBERTSON INC |NOTIFICATION TIME: 09:03[EDT]|
| CITY: RICHMOND REGION: 2 |EVENT DATE: 08/05/2003|
| COUNTY: STATE: VA |EVENT TIME: 06:30[EDT]|
|LICENSE#: 45-08890-02 AGREEMENT: N |LAST UPDATE DATE: 08/05/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JAMES MOORMAN R2 |
| |DOUG BROADDUS NMSS |
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| NRC NOTIFIED BY: BILL BRIODY | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BLO1 20.2201(a)(1)(i) LOST/STOLEN LNM>1000X | |
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EVENT TEXT
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| STOLEN MODEL 3411 TROXLER GAUGE |
| |
| A Troxler gauge model # 3411 serial # 10605 containing 4.8 millicuries of |
| Cs-137 (serial # 408040) and 38.8 millicuries Am-241:Be (serial # 462027) |
| was stolen from the back of the technician's pickup truck which was parked |
| in his yard in Norfolk, VA. The gauge was locked in its molded case and |
| chained to the truck. The chain had been cut, and the gauge and case were |
| removed sometime early this morning or late last night from the truck. The |
| police were called to the scene and are investigating. No press release has |
| been issued at this time and no reward has been offered. The licensee |
| notified Reg 2. |
| |
| * * * UPDATE AT 1437 EDT ON 08/04/03 FROM BILL BRIODY TO JOLLIFFE * * * |
| |
| At approximately 1200 EDT on 08/04/03, a private citizen found the gauge |
| on the side of I-64 in the Norfolk, VA area. The lock on the case had been |
| cut and there was no significant damage to the case. The sources were |
| undamaged and intact inside the case. The citizen took the gauge to his |
| home and notified the VA Department of Transportation who took possession of |
| the gauge. The licensee plans to submit a written report to NRC Region 2. |
| |
| |
| Notified R2DO Steve Cahill and NMSS Doug Broaddus. |
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