Alert

The NRC is shutdown due to the lapse in appropriations. Exempted activities to maintain critical health and safety activities and progress on critical activities, including activities outlined in Executive Order 14300, as described in the OMB Approved NRC Lapse Plan will continue.

Event Notification Report for February 24, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/21/2020 - 2/24/2020

** EVENT NUMBERS **

54526

54527

Agreement State	Event Number: 54526
Rep Org: MA RADIATION CONTROL PROGRAM Licensee: MASSACHUSETTS GENERAL HOSPITAL Region: 1 City: Boston State: MA County: License #: 60-0055 Agreement: Y Docket: NRC Notified By: KENATH TRAEGDE HQ OPS Officer: HOWIE CROUCH	Notification Date: 02/14/2020 Notification Time: 16:01 [ET] Event Date: 02/13/2020 Event Time: 13:45 [EST] Last Update Date: 02/14/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): BRICE BICKETT (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE OF YTTRIUM-90 DURING TREATMENT

"A medical event was reported to the Massachusetts Radiation Control Program on Friday, February 14, 2020. A patient receiving a therapeutic radiation dose to the right lobe of the liver using Y-90 Theraspheres in 2 fractionated doses was intended to receive 135 Grays for each fraction. The patient was administered 45.5 Grays for the first fraction and 129.4 Grays for the second. The first fraction underdosed the right lobe of the liver by greater than 50 percent and differed from the prescribed dose by greater than 0.5 Sv (50 rem) effective dose equivalent. The actual underdose for the first fraction was 8,950 rads. This exceeds the reporting limits of 10 CFR 35.3045(a)(1)(i)(c), 'Report and Notification of a Medical Event,' and 105 CMR 120.594(A)(1)(a)(3).

"The licensee is investigating the cause of the event and will be reporting the results to the Massachusetts Radiation Control Program. "

Agreement State	Event Number: 54527
Rep Org: MAINE RADIATION CONTROL PROGRAM Licensee: MB-MICROTECH USA INC. Region: 1 City: DEERFIELD BEACH State: FL County: License #: ME 05331 Agreement: Y Docket: NRC Notified By: CATHERINE PERHAM HQ OPS Officer: BRIAN LIN	Notification Date: 02/14/2020 Notification Time: 16:37 [ET] Event Date: 02/14/2020 Event Time: 14:44 [EST] Last Update Date: 02/14/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): BRICE BICKETT (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MISSING TRITIUM WATCHES

The following is a synopsis of an email received from the Maine Radiation Control Program:

Fifty-two [self-luminous] watches containing 100 milliCuries each of Tritium were reported as missing or stolen from a shipment delivered to OKO International of Deerfield Beach, Florida. The watches were in transit from Hong Kong to Windsor, Maine. They were part of a shipment of 32 boxes containing a total of 2365 watches. Seven boxes were torn during transport and were re-packaged into five boxes. Upon arrival in Florida, there were 52 watches missing. The brand of watch is reported as an Aragon, with no model or serial number provided yet. Transport was via a common carrier. The licensee reported the theft to the Maine Radiation Control Department at 1444 [EST] on Friday, February 14, 2020. An open investigation is still ongoing with the state of Maine.

Maine Incident No.: ME 20-001

Page Last Reviewed/Updated Wednesday, March 24, 2021