Event Notification Report for March 16, 2011
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/15/2011 - 03/16/2011
Agreement State
Event Number: 46718
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
Region: 4
City: LITTLE ROCK State: AR
County:
License #: ARK-001-02110
Agreement: Y
Docket:
NRC Notified By: STEVE MACK
HQ OPS Officer: DONG HWA PARK
Licensee: UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
Region: 4
City: LITTLE ROCK State: AR
County:
License #: ARK-001-02110
Agreement: Y
Docket:
NRC Notified By: STEVE MACK
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/01/2011
Notification Time: 16:03 [ET]
Event Date: 03/16/2011
Event Time: 00:00 [CDT]
Last Update Date: 05/06/2011
Notification Time: 16:03 [ET]
Event Date: 03/16/2011
Event Time: 00:00 [CDT]
Last Update Date: 05/06/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RYAN LANTZ (R4DO)
PAUL MICHALAK (FSME)
RYAN LANTZ (R4DO)
PAUL MICHALAK (FSME)
AGREEMENT STATE REPORT - YTTRIUM-90 MICROSPSHERES ADMINISTERED DOSE LESS THAN PRESCRIBED DOSE
The following was received from the State of Arkansas via email:
"On March 16, 2011, a patient was scheduled for two administrations of Y-90 microspheres. The first dose administration was conducted without incident. As the second dose was being delivered, the syringe plunger was accidentally rotated so that the stopper inside the syringe was engaged momentarily causing a pause in administration. Due to the pause, the microspheres in the catheter at the time of the pause settled in the catheter and were not administered to the patient.
"The facility has contacted the manufacturer of the administration device.
"On the morning of March 17, 2011, Interventional Radiology informed the referring physician, and patient of the event.
"Conditions requiring reporting of this event:
"The dose differs from the prescribed dose by more than 50 Rem to an organ The delivered dose of 69.56 Gy was 24.44 Gy (2444 rads) less than the optimal dose of 94 Gy and 10.44 Gy (1044 rads) less than the minimal dose in the prescription range. And the total dose delivered differs from the prescribed dose by twenty percent (20%) or more. The total dose delivered, 69.56 Gy, differed by twenty-six percent (26%) from the optimal dose of 94 Gy and was outside the treatment prescription range of 80-150 Gy.
"Arkansas Event Number: 03-11-03"
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.
* * * UPDATE FROM KAYLA AVERY (VIA EMAIL) TO HOWIE CROUCH AT 0821 EDT ON 5/6/11 * * *
"Corrective actions concerning the TheraSphere medical event were submitted to the Arkansas Department of Health. The University of Arkansas for Medical Sciences (UAMS) now requires that all Interventional Radiology staff and residents who will participate in the injection of Y-90 TheraSpheres will receive training on the injection technique prior to administering the radioisotope. The staff will practice the injection process by using normal saline. The staff has also been instructed to administer the dose in a continuous manner without pause. Lastly, the catheter tubing was previously being flushed three times, as recommended by the manufacturer, but the tubing will now be flushed at least five times.
The Arkansas Department of Health considers this incident to be closed."
Notified R4DO (Proulx) and FSME EO (McIntosh).
The following was received from the State of Arkansas via email:
"On March 16, 2011, a patient was scheduled for two administrations of Y-90 microspheres. The first dose administration was conducted without incident. As the second dose was being delivered, the syringe plunger was accidentally rotated so that the stopper inside the syringe was engaged momentarily causing a pause in administration. Due to the pause, the microspheres in the catheter at the time of the pause settled in the catheter and were not administered to the patient.
"The facility has contacted the manufacturer of the administration device.
"On the morning of March 17, 2011, Interventional Radiology informed the referring physician, and patient of the event.
"Conditions requiring reporting of this event:
"The dose differs from the prescribed dose by more than 50 Rem to an organ The delivered dose of 69.56 Gy was 24.44 Gy (2444 rads) less than the optimal dose of 94 Gy and 10.44 Gy (1044 rads) less than the minimal dose in the prescription range. And the total dose delivered differs from the prescribed dose by twenty percent (20%) or more. The total dose delivered, 69.56 Gy, differed by twenty-six percent (26%) from the optimal dose of 94 Gy and was outside the treatment prescription range of 80-150 Gy.
"Arkansas Event Number: 03-11-03"
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.
* * * UPDATE FROM KAYLA AVERY (VIA EMAIL) TO HOWIE CROUCH AT 0821 EDT ON 5/6/11 * * *
"Corrective actions concerning the TheraSphere medical event were submitted to the Arkansas Department of Health. The University of Arkansas for Medical Sciences (UAMS) now requires that all Interventional Radiology staff and residents who will participate in the injection of Y-90 TheraSpheres will receive training on the injection technique prior to administering the radioisotope. The staff will practice the injection process by using normal saline. The staff has also been instructed to administer the dose in a continuous manner without pause. Lastly, the catheter tubing was previously being flushed three times, as recommended by the manufacturer, but the tubing will now be flushed at least five times.
The Arkansas Department of Health considers this incident to be closed."
Notified R4DO (Proulx) and FSME EO (McIntosh).
Power Reactor
Event Number: 46677
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [2] [] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: CHRIS WEICHLER
HQ OPS Officer: HOWIE CROUCH
Region: 1 State: PA
Unit: [2] [] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: CHRIS WEICHLER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/17/2011
Notification Time: 00:01 [ET]
Event Date: 03/16/2011
Event Time: 16:47 [EDT]
Last Update Date: 03/17/2011
Notification Time: 00:01 [ET]
Event Date: 03/16/2011
Event Time: 16:47 [EDT]
Last Update Date: 03/17/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DON JACKSON (R1DO)
DON JACKSON (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
HIGH PRESSURE COOLANT INJECTION DECLARED INOPERABLE
"On 03/16/11, at 1647 [EST], Peach Bottom Atomic Power Station Unit 2 declared the High Pressure Coolant Injection system inoperable for a condition found during testing which could cause the system to malfunction when swapping suction sources. While lined up to the suppression pool suction flow path, unsatisfactory results were obtained while venting for system fill verification, indicating potential voiding of a portion of the pump discharge piping. Unit 2 HPCI remains available while aligned to its normal suction, the condensate storage tank.
"This report is being submitted pursuant to 10CFR 50.72(b)(3)(v)(D).
"The NRC resident has been informed of this notification."
"On 03/16/11, at 1647 [EST], Peach Bottom Atomic Power Station Unit 2 declared the High Pressure Coolant Injection system inoperable for a condition found during testing which could cause the system to malfunction when swapping suction sources. While lined up to the suppression pool suction flow path, unsatisfactory results were obtained while venting for system fill verification, indicating potential voiding of a portion of the pump discharge piping. Unit 2 HPCI remains available while aligned to its normal suction, the condensate storage tank.
"This report is being submitted pursuant to 10CFR 50.72(b)(3)(v)(D).
"The NRC resident has been informed of this notification."