Semantic search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 40672 | 15 March 2004 04:00:00 | 10 CFR 20.2201(a)(1)(ii) | Loss of Licensed Material | The Department of Veterans Affairs is reporting a loss of licensed material. The loss occurred at a medical broad-scope permittee authorized under the master materials license issued to the Department of Veterans Affairs. The permittee is VA Boston Healthcare System, Boston, Massachusetts. The loss was discovered by the permittee Radiation Safety Officer (RSO) on March 15, 2004. The RSO discovered a container of solid animal waste containing approximately 350 micro-Curies of I-125 solid was disposed by transfer to a biological waste vendor and incinerated by the vendor as non-radioactive animal waste. The permittee does not anticipate any exposure to individuals based on the loss. The permittee has taken measures to prevent a recurrence of the loss. The basis for reporting the loss is under 10 CFR 20.2201(a)(ii) in that the permittee disposed of licensed material in a quantity greater than 10 times the quantity specified in 10 CFR 20, Appendix C, and is still missing at this time. The licensed material cannot be recovered. Per 10 CFR 20.2201(b), the Department of Veterans Affairs will evaluate the circumstances related to the loss and submit a written report to NRC, Region 3, within 30 days of this notification. | ||
| ENS 41044 | 16 September 2004 16:30:00 | 10 CFR 20.1906(d)(1) | Surface Contamination on Radioactive Material Package Exceeding Limits | The Department of Veterans Affairs, National Health Physics Program reported a package that exceeded the limits for removable radioactive surface contamination. The package was received on September 16, 2004, by a permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA. The permittee is the Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin. This event is reported under 10 CFR 20.1906(d)(1) in that the package, an ammo box being used to deliver radioactive materials, had approximately 11,000 disintegrations per minute per square centimeter removable radioactive contamination on the outside. The contamination was limited to one small spot on the ammo box exterior. The interior of the box was not contaminated. The contamination was identified as 99M-Tc. The Cardinal Health Nuclear Pharmacy Services delivered the package. The permittee Radiation Safety Officer notified the vendor about the package. There was no personnel contamination involved. | ||
| ENS 41439 | 24 February 2005 18:35:00 | 10 CFR 20.1906(d)(1) | Removable Radioactive Surface Contamination on a Package | The Department of Veterans Affairs, National Health Physics Program reported that a package received at one of its facilities had removable radioactive surface contamination that exceeded limits. The package was received on 2/24/05 at the VA Southern Nevada Health Care System in Las Vegas, NV. The package had a contamination level of 85,000 DPM over a 300 square cm wipe. The contamination was identified as Technetium-99M via spectral analysis. The package was received from Bio Tech, a commercial pharmacy in Las Vegas. Southern Nevada Health Care notified Bio Tech and the pharmacy has sent a representative to the facility to assist in the investigation. The package was delivered by a pharmacy delivery vehicle and the status of any contamination in the vehicle is unknown. There was no apparent damage to the package. Appropriate steps have been taken to prevent the spread of contamination. | ||
| ENS 41443 | 24 February 2005 05:00:00 | 10 CFR 35.3045(a)(1) | Medical Event | The following information was provide by the licensee via facsimile: (The Department of Veteran Affairs National Health Physics Program called) per 10 CFR 35.3045 to notify (the NRC) of a possible medical event at the VA Medical Center, Durham, North Carolina, a permittee under the VA license. This event was discovered on February 25, 2005. On February 24, 2005, a permanent-implant prostate brachytherapy procedure was performed at the medical center. 84 Iodine-125 seeds were implanted in the patient. These seeds had around 400 microcuries per seed. A number of seeds were mistakenly placed in fatty tissue, outside of the intended area of treatment. Based on a preliminary evaluation, a possible medical event occurred since the dose to the prostate was possibly more than 20 percent less than that prescribed and a dose to tissue other than the treatment site is possibly more than 50 rem and greater than 50% of the prescribed dose. The authorized user notified the patient and will notify the referring physician within 24-hours of discovery. The National Health Physics Program intends to conduct a reactive inspection next week. | ||
| ENS 41855 | 19 July 2005 05:00:00 | 10 CFR 20.1906(d)(1) | Radioactive Package with Removable Surface Contamination Exceeding a Limit | Licensee: Department of Veterans Affairs, National Health Physics Program License # 03-23853-01VA Permittee: VA Gulf Coast Veterans Health Care System, Biloxi, Mississippi Date of event: July 19, 2005, about 1000 CDT Date and Time NHPP notified: July 19, 2005, 1700 CDT A radioactive package was received from the commercial radiopharmacy at about 1000 hours CDT. The nuclear medicine technologist followed routine procedures for opening radioactive packages and performed a wipe test on the outside of the package. The wipe test results were 13,000 dpm / 300 cm2. Slight contamination was located on the inside of the package. The technologist immediately notified the radiopharmacy of the contamination. The radiopharmacy is Cox Nuclear Pharmacy in Biloxi, MS. NHPP representatives will follow-up with the permittee on July 20, 2005. A copy of this text has been sent to Kevin Null, NRC Region III Event Number: 41855
The basis for retracting the event is that the package had approximately 49 DPM per cm2 removable radioactive contamination on the outside, which is less than the reporting requirement under 49 CFR 173.443. This retraction was coordinated with NRC Region III." R3DO (Patrick Louden), R1DO (Rich Conte) and NMSS EO (Michele Burgess) notified. | ||
| ENS 42117 | 30 August 2005 06:00:00 | 10 CFR 20.2201(a)(1)(ii) | Loss of Radioactive Material | I am calling per 10 CFR 20.2201(a)(ii) to notify you of a possible loss of radioactive material at the VA Medical Center, New Orleans, Louisiana, a permittee under the VA license. This incident occurred on or around August 30, 2005, and was discovered October 7, 2005. This possible incident resulted from the flooding of the radioactive waste storage room at the medical center and involved the loss of radioactive materials. The materials which are considered lost are Iodine 131 and Iodine 125. The unsealed materials were in waste containers and may have washed out of the containers when the waste room was flooded. The dilution of the small amount of activity in the floodwaters precludes any possible public dose or health and safety concern. These circumstances are considered a possible incident since a technical evaluation to estimate the loss is not based on quantitative measurements or surveys. Also, the tags and waste records attached to the containers were obliterated by the floodwaters. Attempts to estimate the activity began on October 7, 2005, and an estimate of the original activity was submitted by the permittee in a preliminary report to the National Health Physics Program on October 24, 2005. A best estimate based on review of storage records, radioactive decay, and observations and measurements in the waste room is that, perhaps, as much as 200 microcuries Iodine 131 and 600 microcuries Iodine 125 in storage August 30, 2005, cannot be specifically located or identified as being present in the waste storage room on October 7, 2005. 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. | ||
| ENS 42485 | 31 December 2005 05:00:00 | 10 CFR 20.2201(a)(1)(i) | Loss of General Licensed Material Due to Improper Disposal During Construction | My name is Gary Williams with the Department of Veterans Affairs, National Health Physics Program (NHPP). I am calling to report a loss of radioactive materials. The loss occurred at a medical permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-2385301VA. The permittee is the Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin. The loss occurred in 2005 and was discovered in April 2006. The basis for the report is under 10 CFR 31.5(c)(10) in that radioactive materials obtained under a general license were lost and the reporting requirements in 10 CFR 20.2201 must be followed. Specifically, the permittee stated one tritium exit sign was apparently disposed or discarded during a facility construction project in 2005. The sign was last seen in 2004. The sign was either of two models. The first model is a 11.5 Curie sign from Shield Source Incorporated. The second model is a 20 Curie sign from SRB Technology. These types of signs were manufactured circa 1994. The Department of Veterans Affairs will evaluate the circumstances related to the loss of radioactive materials and submit a written report to NRC, Region III, within 30 days. HOO NOTE: The Department of Veterans Affairs coordinates all reports to the NRC from their NHPP Director's Office located in Little Rock, AR. NRC oversight for the VA Master Materials licensee is assigned to NRC Region III. 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. | ||
| ENS 42507 | 18 April 2006 17:45:00 | 10 CFR 20.1906(d)(1) | Receipt of Package with Surface Contamination | Licensee called pursuant to 10 CFR 20.1906, to report the receipt of a package of radioactive material with removable surface contamination slightly exceeding the limits of 10 CFR 71.87(i). The package was received at approximately 1245 CT today by the VA Medical Center in Birmingham, AL. Several wipe tests were performed on the package. The one showing the greatest removable contamination indicated 283 dpm/cm2, slightly exceeding the regulatory limit of 220 dpm/cm2. The package was received from a commercial nuclear radiopharmacy, Birmingham Nuclear Pharmacy, in Birmingham AL. The final delivery carrier has been notified. The radionuclide is Technetium-99m. HOO NOTE: The Department of Veterans Affairs coordinates all reports to the NRC from their NHPP Director's Office located in Little Rock, AR. NRC oversight for the VA Master Materials licensee is assigned to NRC Region III. Permittee: VA Medical Center, 700 South 19th Street, Birmingham, Alabama, 35233, Permit Number 01-00643-02. | ||
| ENS 43265 | 31 May 2006 05:00:00 | 10 CFR 35.3045(a)(1) | Medical Event - Patient Received Dose Greater than Prescribed | The possible medical event occurred at a broad-scope permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA. The permittee is VA Eastern Colorado Health Care System, Denver, Colorado. The possible medical event occurred on May 31, 2006. The possible medical event was discovered on March 28, 2007. The basis for the possible medical event is under 10 CFR 35.3045(a)(1)(i) and involved administration of a dose different from the dose prescribed in the written directive. Specifically, the written directive for a patient therapy procedure listed the dose to be 15 millicuries Iodine 131 when in fact 30 millicuries was given to the patient. Since the clinical intent was for the patient to receive 30 millicuries, the possible medical event will not have any adverse impact on the patient. The permittee has implemented corrective actions to prevent a recurrence of the circumstances that resulted in the possible medical event. The Department of Veterans Affairs will evaluate the circumstances related to the possible medical event and submit a written report to NRC, Region III, within 15 days.
This event has been reviewed and determined to be a reportable medical 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. | ||
| ENS 43917 | 17 January 2008 05:00:00 | 10 CFR 35.3045(a)(2) | Potential Overexposure | The possible medical event occurred at a broad-scope permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA. The permittee is VA Boston Healthcare System, Boston, Massachusetts. The possible medical event occurred on January 17, 2008, and was discovered the same day. The basis for the possible medical event is under 10 CFR 35.3045(a)(2) and involved administration of radiopharmaceutical that might have resulted in more than 50 rem to tissue and involved a wrong route of administration. Specifically, a F-18 FDG injection of approximately 3.6 millicuries was infiltrated into a patient's arm. The Department of Veterans Affairs and permittee are reviewing the possible medical event circumstances and the dose calculation methods. The permittee informed the patient and referring physician.
The basis for retracting the event is that infiltration is not considered to be a wrong route of administration. This basis was communicated to NHPP (National Health Physics Program) in a phone call received from our NRC Region III Project Manager (Cassandra Frazier) on March 7, 2008 at 4:40 pm. Notified R1DO (Lorson), R3DO (Ring), and FSME (Burgess). | ||
| ENS 43961 | 4 February 2008 22:45:00 | 10 CFR 20.2202(b)(1) | Potential Over-Exposure of Worker Who Operates a Fluoroscopy Machine | Radiation Safety Officer of Boston VA Hospital made a 24-hour report that that a worker who operates a fluoroscopy machine, which produces x-rays from an accelerator and is used in cardiology, may have received exposure greater than allowed limits. The worker's radiation badge is normally read monthly, with a typical exposure of 80-200 mrem. However, his badge from July 2007 was not read until December 2007. Landauer read the badge on December 23, 2007, and reported a reading of 5,700 mrem, which they reported by letter dated January 23, 2008, to the Radiation Safety Officer, who received the information February 5, 2008. An investigation has commenced to determine whether some of the badge reading may have been when the worker was not wearing the badge, or due to other sources. * * * RETRACTION FROM T. HUSTON TO P. SNYDER ON 3/6/08 AT 1510 * * * This report is retracted based on the fact that "the reported exposure was to a dosimeter and not to an individual. In addition, the exposure did not involve byproduct materials." Notified R3DO (P. Pelke), R1DO (J. Caruso), and FSME (S. Wastler). | ||
| ENS 44076 | 18 March 2008 17:00:00 | 10 CFR 20.1906(d)(1) | Receipt of Package with Surface Contamination | The following script was provided in a telephone call to the NRC Operations Center: My name is Thomas Huston with the Department of Veterans Affairs, VHA National Health Physics Program. This report involves NRC master materials license No. 03-23853-01VA. I am calling to report receipt of three packages of radioactive material with removable surface contamination on the outside of the package greater than the limits in 10 CFR 71.87(i). The three packages were received at approximately 1:00 PM ET, March 18, 2008 by the VA Medical Center in West Palm Beach, FL. Wipe tests performed on the three packages indicated the following removable contamination levels: 24700 dpm/cm2, 12880 dpm/cm2, and 35570 dpm/cm2 as compared to the regulatory limit of 22 dpm/cm2. The three packages contained Co-57 flood sources and were received from a commercial vendor, Eckert & Ziegler (Isotope Products Laboratories), of Valencia, CA. The final delivery was by common carrier. The final delivery carrier was notified of the contaminated packages at approximately 1630 hrs ET on March 18, 2008 by the VA Medical Center's Radiation Safety Officer. The vendor was notified of the contamination at approximately 1730 hr on March 18, 2008 by the VA Medical Center's Radiation Safety Officer. The radionuclide involved is believed to be Co-57; however, additional confirmatory measurements are being made. Additional information: The Department of Veterans Affairs coordinates all reports to the NRC from the NHPP Director's Office located in North Little Rock, AR. NRC oversight for the VA Master Materials licensee is assigned to NRC Region 3. Address of permittee involved in this event: VA Medical Center, 7305 North Military Trail, West Palm Beach, Florida 33410, VHA Permit Number 09-25328-01. | ||
| ENS 44208 | 13 May 2008 17:15:00 | 10 CFR 20.1906(d)(1) | "(The Department of Veterans Affairs Called) to Report Receipt of One Package of Radioactive Material with Removable Surface Contamination on the Outside of the Package Greater than the Limits in 10 Cfr 71.87(I). | The package was received at approximately 12:15 PM Eastern Time (ET), May 13, 2008 by the VA Medical Center in West Palm Beach, FL. A wipe test performed on the external surface of the package around 12:30 PM ET indicated a removable contamination level of 42 dpm/cm2 as compared to the regulatory limit of 22 dpm/cm2. The package contained a PET radioactive drug with Fluorine-18 (F-18) shipped from Cardinal Health of Jupiter, Florida. The vendor/shipper also serves as the delivery carrier. The shipper/delivery carrier was notified of the contaminated package at approximately 12:55 PM ET by the VA Medical Center's Radiation Safety Officer. Spectral measurements indicated that the contaminant involved is F-18. The package did not appear to be damaged. The package is being held for radiological decay and will be returned to the vendor in a couple of days. | ||
| ENS 44522 | 24 September 2008 05:00:00 | 10 CFR 35.3045(a)(1) | Medical Dose Less than 80% of Prescribed Dose | In response to medical events discovered at the VA Medical Center Philadelphia, which have been reported under Event Number 44219, reviews are ongoing of samples of patient charts from other VA facilities with permanent prostate seed implant brachytherapy programs. As the result of these ongoing reviews, possible medical events were discovered on September 24, 2008, for 7 patients treated at the VA Medical Center in Jackson, Mississippi. These 7 possible medical events involved seed distributions in the patients that may result in D90 doses less than 80% of the prescribed doses. These circumstances are interpreted as meeting the definition of a medical event under 10 CFR 35.3045. (The D90 is the dose that covers 90% of the volume of the prostate.) The VHA National Health Physics Program will ensure that the medical center follows NRC requirements for notification of the patients. These treatments and their possible effects on the patients are under review by medical experts. A 15-day written report of these 7 possible medical events will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these possible medical events. Additional Information Department of Veterans Affairs has a Master Materials License (MML) from the NRC: License No. 03-23853-01VA. Permits are issued under the MML to VA facilities. The VA submits reports to the NRC through the VHA's National Health Physics Program office located in North Little Rock, AR. Address of permittee involved in this event: VA Medical Center, 1500 East Woodrow Wilson Drive, Jackson, Mississippi 39216. VHA permit number of permittee involved in event: Permit No. 23-08786-01.
This report is an update to Event Report Number 44522. As the result of an ongoing review, an additional possible medical event was discovered on October 7, 2008. This brings the total number of possible medical events to eight (8) under Event Report Number 44522. The circumstances are similar to those previously reported for this event number. A 15-day written report of this additional medical event will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III) of this additional possible medical event. Notified the R3DO (Lara) and FSME (Einberg).
This report is an update to Event No. 44522. An additional medical event was discovered on October 29, 2008, for a patient treated at the VA Medical Center in Jackson, Mississippi. This medical event involved a patient who had undergone permanent implant prostate seed brachytherapy using iodine-125 seeds. The resulting seed distribution in the patient was associated with a D90 dose to the treatment site that was less than 80% of the prescribed dose. The circumstances were interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(1). A total of eight (8) events have been previously reported to the NRC under this event number. This additional event brings the total number of events to nine (9) for this facility. A 15-day written report on this additional medical event will be submitted to NRC Region III. I have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of this additional medical event. Notified R3DO (Kozak) and FSME (Burgess).
This report is an update to Event No. 44522. One additional medical event was discovered on December 16, 2008, for a patient treated at the VA Medical Center, Jackson, Mississippi. This medical event involved a patient who had undergone permanent implant prostate seed brachytherapy using iodine-125 seeds. The resulting seed distribution in the patient was associated with a D90 dose to the treatment site that was less than 80% of the prescribed dose. The circumstances were interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(1). A total of nine (9) events have been previously reported to the NRC under this event number. This additional event brings the total number of events to ten (10) for this facility. A 15-day written report on this additional medical event will be submitted to NRC Region III. We have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of this additional medical event. Notified R3DO (Skokowski) and FSME (Flannery). 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. | ||
| ENS 44842 | 9 February 2009 21:00:00 | 10 CFR 20.1906(d)(1) | Removable Surface Contamination Above Limits | Two packages containing radioactive material were received with removable surface contamination on the outside of the packages greater than the limit cited in 10 CFR 71.87(i). The two packages were received at approximately 4:00 p.m. EDT, February 9, 2009, by the VA Medical Center in West Palm Beach, FL. The two packages contained Germanium-68 PET/CT calibration sources. Wipe tests performed on the two packages indicated the following removable contamination levels: 802 dpm/cm2 on one package and 400 dpm/cm2 on the other, as compared to the regulatory limit of 220 dpm/cm2 for beta-gamma emitters. Spectral measurements (gamma energy) of the wipes were consistent with the radionuclide contained in the package. The final delivery carrier was notified of the contaminated packages at approximately 5:00 p.m. EDT on February 9, 2009, by the VA Medical Center's Radiation Safety Officer. The shipper (Eckert Ziegler Isotope Products) was also notified (by recorded voice message) of the contaminated packages. Licensee will notify our NRC Project Manager (Cassandra Frazier, NRC Region III) of this event. Additional information: Permits are issued under the license to Veterans Health Administration facilities. The permit number for the facility involved in these medical events is VHA Permit No. 09-25328-01. | ||
| ENS 45948 | 24 May 2010 12:45:00 | 10 CFR 20.1906(d)(2) | Package Surface Contamination in Excess of Reporting Limits | (A representative) with the Department of Veterans Affairs, VHA National Health Physics Program provided the following report. This report involves NRC master materials license no. 03-23853-01VA. (The VHA representative) called, as required by 10 CFR 20.1906(d), to report receipt of a package of radioactive material with removable surface contamination on the outside of the package greater than reporting limits. The package was received today (May 24, 2010) at around 7:45 AM CT by the Central Texas Veterans Healthcare System, Temple, Texas. A wipe test performed on the external surface of the package indicated a removable contamination level of 562 dpm/cm2 as compared to the regulatory limit of 220 dpm/cm2. Surveys inside the package did not indicate elevated contamination. The package contained Tc-99m (Technetium) labeled radiopharmaceuticals and was shipped from Specialty Pharmaceutical Services, Inc., in Temple, Texas. The vendor/shipper also serves as the delivery carrier. The VA facility staff immediately notified Specialty Pharmaceutical Services, Inc. about the contaminated package at about 9:30 AM CT. (The VHA representative) will notify the NRC Project Manager at NRC Region III of this event. The permittee holds VHA Permit Number 42-10739-03. | ||
| ENS 46301 | 1 October 2010 13:11:00 | 10 CFR 20.1906(d)(1) | Non-Fixed Rad Surface Contamination Greater than Limits | (This report is being made) to report receipt of a package of radioactive material with removable surface contamination on the outside of the package greater than reporting limits. The package was received today, October 1, 2010, at around 0811 CDT by the Amarillo Veterans Administration (VA) Health Care System, Amarillo, Texas. A wipe test performed on the external surface of the package indicated a removable contamination level of 1300 dpm/cm2 as compared to the regulatory limit of 220 dpm/cm2. The package was immediately bagged and secured within the VA nuclear medicine department where it will be stored for decay. Wipes were taken throughout the department with all readings being at background levels. The package contained 80 milliCuries of Tc-99m-labeled radiopharmaceuticals and was shipped from Panhandle Pharmacy, Amarillo, Texas. The vendor/shipper also serves as the delivery carrier. The VA nuclear medicine staff immediately notified the carrier before he left the nuclear medicine department and also contacted staff at Panhandle Pharmacy about the contaminated package at around 0825 CDT. We will notify our NRC Project Manager at NRC Region III of this event. The VA facility RSO indicated that the VA staff offered to survey the carrier, but he declined. The external exposure rate readings on the package were within limits: 0.4 mR/hr on contact. The receiving facility was scanned for contamination. The results came back as reading background. | ||
| ENS 48858 | 27 March 2013 17:48:00 | 10 CFR 20.1906(d)(1) | Surface Contamination on Outside of Package Exceeding Nrc Reporting Limits | Per 10 CFR 20.1906(d)(1), (the Veterans Health Administration (VHA) is) reporting receipt of a package of radioactive material with removable surface contamination on the outside of the package greater than NRC reporting limits. The package was received today (March 27, 2013) around 12:48 PM CDT by South Texas Veterans Health Care System, San Antonio, Texas. This medical center holds permit number 42-15881-01 under the VHA master materials license. Wipe tests performed on the external surface of the package indicated a removable contamination level of 993 dpm/cm2 as compared to the regulatory limit of 220 dpm/cm2 for beta-gamma emitters. The package contained one 30-millicurie dosage of Technetium-99m and was shipped and delivered by Cardinal Health in San Antonio, Texas. The inner packaging materials were slightly contaminated but the dosage itself was not impacted and was able to be used. The VA facility Nuclear Medicine Technologist immediately notified, by telephone, the Radiation Safety Officer at Cardinal Health about the contaminated package. As corrective actions: the packaging materials were bagged and set aside in a restricted area at the medical center for decay; staff with access to the area were notified about the contaminated packaging materials; and surveys were performed in the package receipt area to ensure that contamination was not spread beyond the area. (Veterans Health Administration) notified NRC Region III (K. Null) by telephone of this event. | ||
| ENS 50833 | 29 December 2014 06:00:00 | 10 CFR 35.3045(a)(1) | Medical Event - Underdose | This is a notification, pursuant to 10 CFR 35.3045(a)(1), of a medical event that occurred at the VA Medical Center, Durham, North Carolina. On December 29, 2014, a dosage of 1.569 millicuries of I-131 sodium iodide was administered to a patient for a diagnostic whole body scan, and the prescribed dosage on the written directive was 2 millicuries. The basis for identifying this as a medical event is that the administered dosage differed from the prescribed dosage by more than 20 percent and the absorbed dose is estimated to differ from that dose that would have resulted from the prescribed dose by more than 50 rem to remnant thyroid tissue. The medical event was discovered today (February 19, 2015) during a routine audit by the facility Radiation Safety Officer. The facility has notified the referring physician and the patient of the medical event. No biological harm to the patient is expected from this under-dosing event. The NHPP (National Health Physics Program) plans to perform a reactive inspection regarding the medical event within the next 10 working days. A 15-day written report for the medical event will be submitted to NRC Region III. National Health Physics Program notified NRC Region III (Patricia Pelke, Chief, Materials Licensing Branch Chief) of the medical event by telephone. Additional information: The Department of Veterans Affairs holds NRC License No. 03-23853-01VA, a master materials license. Permits are issued under the license to Veterans Health Administration facilities. The VHA permit number for the facility involved in this medical event is 32-01134-01. National Health Physics Program makes required notifications to NRC." 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. | ||
| ENS 51069 | 24 February 2015 06:00:00 | 10 CFR 35.3045(a)(1) | Incorrect Dose Recorded on Prescription Directive | This is a notification, pursuant to 10 CFR 35.3045(a)(1), of a medical event that occurred at the VA Salt Lake City Health Care System, Salt Lake City, Utah. On February 24, 2015, a dosage of 30.8 millicuries of I-131 sodium iodide (capsule form) was administered to a patient for a thyroid ablation. The prescribed dosage on the written directive was incorrectly annotated as 3 millicuries. The basis for identifying this as a medical event is the administered dosage differed from the prescribed dosage, as annotated on the written directive, by more than 20 percent. The medical event was discovered today (May 13, 2015) during an inspection, conducted by the National Health Physics Program (NHPP). Interview of the Radiation Safety Officer revealed the standard dosage for a thyroid ablation is 30 millicuries of I-131 sodium iodide (capsule form). Interview of the authorized user (a physician) revealed the intended prescription was for 32 millicuries of I-131 sodium iodide (capsule form). No biological harm to the patient is expected since the thyroid ablation was successfully performed. The patient and attending physician were not informed of the incorrect annotation on the written directive since the thyroid ablation was successfully performed, as clinically intended, with a dosage of I-131 sodium iodide (capsule form) within an acceptable range of the authorized user's intent. The inspection is ongoing with causal factors and corrective actions being developed. Additional information will be provided in a 15-day written report, to be submitted to NRC Region III. National Health Physics Program notified NRC Region III (Patricia Pelke, Chief, Materials Licensing Branch Chief) of the medical event by telephone. The Department of Veterans Affairs holds NRC License No. 03-23853-01VA, a master materials license. Permits are issued under the license to Veterans Health Administration facilities. The VHA permit number for the facility involved in this medical event is 43-03299-01. National Health Physics Program makes required notifications to NRC. " 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. | ||
| ENS 54822 | 5 August 2020 18:00:00 | 10 CFR 35.3045(a)(3) | Medical Event | A Y-90 microsphere therapy administration was performed on August 5, 2020, (at VA Boston Healthcare System in Boston, Massachusetts). The prescribed dose was intended for the right lobe of the liver. Post implant imaging on that day indicated that the dosage of microspheres was unintentionally administered to a portion of the left lobe of the liver. The patient and the referring physician have been notified. The National Health Physics Program (NHPP) will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045. NHPP notified our NRC Region III Project Manager (Parker). 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. |