Event Notification Report for March 17, 2011
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/16/2011 - 03/17/2011
Power Reactor
Event Number: 46678
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATTHEW PARKER
HQ OPS Officer: DONALD NORWOOD
Region: 2 State: SC
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATTHEW PARKER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/17/2011
Notification Time: 13:58 [ET]
Event Date: 03/17/2011
Event Time: 12:50 [EDT]
Last Update Date: 03/17/2011
Notification Time: 13:58 [ET]
Event Date: 03/17/2011
Event Time: 12:50 [EDT]
Last Update Date: 03/17/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
REBECCA NEASE (R2DO)
REBECCA NEASE (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
OFFSITE NOTIFICATION DUE TO VEHICLE FIRE
"Vehicle fire outside the protected area in the owner controlled area. Offsite fire department contacted and responded to site. Fire has been extinguished. Fire was limited to vehicle and no plant equipment was affected. Event had no affect on plant operation."
The licensee notified the State of North Carolina, the State of South Carolina, York county, Gaston county, and Mecklenburg county. The licensee notified the NRC Resident Inspector.
"Vehicle fire outside the protected area in the owner controlled area. Offsite fire department contacted and responded to site. Fire has been extinguished. Fire was limited to vehicle and no plant equipment was affected. Event had no affect on plant operation."
The licensee notified the State of North Carolina, the State of South Carolina, York county, Gaston county, and Mecklenburg county. The licensee notified the NRC Resident Inspector.
Agreement State
Event Number: 46683
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: ABBOTT NORTHWESTERN HOSPITAL
Region: 3
City: MINNEAPOLIS State: MN
County:
License #: 1007-209-27
Agreement: Y
Docket:
NRC Notified By: BRYCE ARMSTRONG
HQ OPS Officer: DONALD NORWOOD
Licensee: ABBOTT NORTHWESTERN HOSPITAL
Region: 3
City: MINNEAPOLIS State: MN
County:
License #: 1007-209-27
Agreement: Y
Docket:
NRC Notified By: BRYCE ARMSTRONG
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/18/2011
Notification Time: 16:13 [ET]
Event Date: 03/17/2011
Event Time: 00:00 [CDT]
Last Update Date: 03/18/2011
Notification Time: 16:13 [ET]
Event Date: 03/17/2011
Event Time: 00:00 [CDT]
Last Update Date: 03/18/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
KENNETH RIEMER (R3DO)
CHRISTEPHER MCKENNEY (FSME)
KENNETH RIEMER (R3DO)
CHRISTEPHER MCKENNEY (FSME)
AGREEMENT STATE REPORT - YTTRIUM-90 MICROSPSHERES ADMINISTERED AT 150% OF PRESCRIBED DOSE
"A medical event took place at Abbott-Northwestern Hospital involving a Yttrium-90 (Y-90) SIR microsphere therapy patient treated on 3/17/2011. It was discovered on 3/18/11, by the radiation oncologist covering the SIRS procedure from the day before, that the delivered amount of Y-90 SIRS wasn't 105% above the prescribed dose as intended, but actually 150% above the prescribed dose. She then brought this error to the attention of the lead medical physicist who was the attending medical physicist responsible for this treatment delivery, for further clarification. Upon investigation, it was deduced that the medical physicist had not read the patient's SIRS therapy (utilizing Y-90 radioactive isotope) written directive prescription correctly. A higher than intended dosage was administered to the patient (1.66 GBq). The correct dosage that was intended to be administered per the written directive was 1.11 GBq. After calculation was made after the incident it was determined that the intended dose to the liver was 30.72 Gy and the actual dose to the liver was 45.93 Gy.
"Contributing factors to the above error identified by the licensee are as follows:
"1. The amount of information presented in the SIRS written directive and the prescribed amount of isotope is hard to discern and is not set apart from all the other numbers presented.
"2. The prescribed activity is manually transferred to a secondary worksheet used in Nuclear Medicine to draw the dose to be administered and this secondary activity worksheet is not verified by a secondary party.
"The licensee stated that to prevent such an event from occurring in the future, the SIRS written directive document will be modified to display the prescribed activity more predominantly on the form as well as a space for initializing by a secondary party that the prescribed dose has been transferred/entered properly on the secondary activity worksheet that is used in Nuclear Medicine to draw the dose to be administered.
"The referring physicians as well as the patient have been or are in the process of being notified of this event.
"According to the licensee's Radiation Oncologist and Interventional Radiologist that were asked to consult, this higher dose would slightly increase the patient's risk of radiation-induced liver disease. The patient, as is standard for all SIRS (Y-90) patients, will receive liver function follow-up testing to track her status."
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.
"A medical event took place at Abbott-Northwestern Hospital involving a Yttrium-90 (Y-90) SIR microsphere therapy patient treated on 3/17/2011. It was discovered on 3/18/11, by the radiation oncologist covering the SIRS procedure from the day before, that the delivered amount of Y-90 SIRS wasn't 105% above the prescribed dose as intended, but actually 150% above the prescribed dose. She then brought this error to the attention of the lead medical physicist who was the attending medical physicist responsible for this treatment delivery, for further clarification. Upon investigation, it was deduced that the medical physicist had not read the patient's SIRS therapy (utilizing Y-90 radioactive isotope) written directive prescription correctly. A higher than intended dosage was administered to the patient (1.66 GBq). The correct dosage that was intended to be administered per the written directive was 1.11 GBq. After calculation was made after the incident it was determined that the intended dose to the liver was 30.72 Gy and the actual dose to the liver was 45.93 Gy.
"Contributing factors to the above error identified by the licensee are as follows:
"1. The amount of information presented in the SIRS written directive and the prescribed amount of isotope is hard to discern and is not set apart from all the other numbers presented.
"2. The prescribed activity is manually transferred to a secondary worksheet used in Nuclear Medicine to draw the dose to be administered and this secondary activity worksheet is not verified by a secondary party.
"The licensee stated that to prevent such an event from occurring in the future, the SIRS written directive document will be modified to display the prescribed activity more predominantly on the form as well as a space for initializing by a secondary party that the prescribed dose has been transferred/entered properly on the secondary activity worksheet that is used in Nuclear Medicine to draw the dose to be administered.
"The referring physicians as well as the patient have been or are in the process of being notified of this event.
"According to the licensee's Radiation Oncologist and Interventional Radiologist that were asked to consult, this higher dose would slightly increase the patient's risk of radiation-induced liver disease. The patient, as is standard for all SIRS (Y-90) patients, will receive liver function follow-up testing to track her status."
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.