Event Notification Report for August 21, 2013

AGREEMENT STATE REPORT - PATIENT GIVEN DOSE PRESCRIBED FOR ANOTHER PATIENT

The following was received from the State of Oregon via facsimile:

"The inpatient was having an Adenosine Myoview stress test. The Nuclear Medicine Technologist took the dose that was already in the dose calibrator (place there earlier by another Nuclear Medicine Technologist). It measured about the same activity as 99m-Tc Myoview would measure in the dose calibrator. The Nuclear Medicine Technologist gave the patient 37.4 millicuries of 99m-Tc DTPA (lung ventilation dose) instead of 30 millicuries of 99m-Tc Myoview. The route of administration for 99m-Tc DTPA is inhalation and the route of administration for 99m-Tc Myoview is intravenous. The 99m-Tc DTPA was intended for a different patient. The patient was informed of the mistake and the stress test will be repeated tomorrow (8/22/13). The ordering physician was also notified of the event. There were no adverse effects to the patient, just delayed the study.

"This will be reported at the next Radiation Safety Committee Meeting along with any actions that will be taken to prevent this in the future."

Oregon Event Number: 13-0031

* * * RETRACTION ON 9/4/13 AT 1310 EDT FROM RICK WENDT TO DONG PARK * * *

"This item is ready for closure. Incident closed. Not a reportable event."

Notified R4DO (Gaddy).

* * * UPDATE ON 9/5/13 AT 1306 EDT FROM RICK WENDT TO PETE SNYDER * * *

The event was not reportable due to the fact that the total organ dose was less than 50 REM.

Notified R4DO (Gaddy).

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.

UNANALYZED CONDITION FOR EMERGENCY DIESEL GENERATOR FUEL OIL PUMPS TRAIN SEPARATION

"On August 21, 2013 at 2000 CDT, it was determined following receipt and review of an NRC position document, that the design of the Monticello Nuclear Generating Plant diesel fuel oil supply system is not consistent with current and historical licensing and design basis documents. This condition affects fuel oil supply from the diesel fuel oil storage tank to both emergency diesel generators and is being reported pursuant to 10CFR50.72(b)(3)(ii) as an unanalyzed condition that could significantly degrade plant safety.

"Actions are in progress to address the unanalyzed condition. The NRC Resident Inspector has been notified."

INADVERTENT SIREN ACTUATION

"On 08/21/2013, the Kewaunee Power Station was notified by Kewaunee County Emergency Management of the inadvertent actuation of siren K-005 at 2100 [CDT]. At the time of the actuation, there was severe weather in the area. The siren stopped actuating at 2125. Kewaunee Power Station requested maintenance crews remove power from the siren to prevent additional actuation until repairs can be made. The resulting loss of siren coverage is 4%. Siren K-005 is a shared siren with Point Beach Nuclear Power Plant. Point Beach control room has been notified."

The licensee has notified the NRC Resident Inspector.

INADVERTENT SIREN ACTUATION

"Point Beach was notified via our EP [emergency plan] manager that emergency plan siren K 5 actuated inadvertently at 2100 [CDT] on 8/21/13, during severe weather. Initial notification of this occurrence was made by Kewaunee County Emergency Management to the Kewaunee Nuclear Plant EP manager. The Kewaunee EP manager in turn notified the Point Beach EP manager. The siren stopped sounding at 2125 on 8/21/13, and was removed from service to prevent additional inadvertent actuations before it is repaired. The loss of coverage for siren K-5, which is the only Point Beach siren out of service at this time, is 1.9%, which is below the 50% loss of coverage requiring additional notifications."

The licensee has notified the NRC Resident Inspector.