Event Notification Report for October 30, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/29/2014 - 10/30/2014
EVENT NUMBERS
50584505805058150582
Non-Agreement State
Event Number: 50584
Rep Org: BEAUMONT HEALTH SYSTEM
Licensee: BEAUMONT HOSPITAL ROYAL OAK
Region: 3
City: ROYAL OAK State: MI
County:
License #: 21-01333-01
Agreement: N
Docket:
NRC Notified By: CHERYL SCHULTZ
HQ OPS Officer: HOWIE CROUCH
Licensee: BEAUMONT HOSPITAL ROYAL OAK
Region: 3
City: ROYAL OAK State: MI
County:
License #: 21-01333-01
Agreement: N
Docket:
NRC Notified By: CHERYL SCHULTZ
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/30/2014
Notification Time: 18:17 [ET]
Event Date: 10/30/2014
Event Time: 10:00 [EDT]
Last Update Date: 10/30/2014
Notification Time: 18:17 [ET]
Event Date: 10/30/2014
Event Time: 10:00 [EDT]
Last Update Date: 10/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
CHRISTINE LIPA (R3DO)
CHRISTINE LIPA (R3DO)
PATIENT RECEIVED DOSE GREATER THAN PRESCRIBED DOSE
"This is a notification of a medical event that occurred on October 30, 2014 at 1000 EDT in which the Y-90 SIR-Sphere dose delivered to the patient's posterior portion of the right lobe of the liver was more than the prescribed dose by 20 percent or more (10 CFR 35.3045). This patient had a dual administration, with the correct dose administered in accordance with the written directive to the anterior portion of the right lobe of the liver (0.43 GBq and 53.4 Gy). The medical event occurred before this, when the patient who was prescribed a dose of 0.39 GBq (64.5 Gy) was administered a dose that was 20.5% more than the prescribed dose. The posterior portion of the right lobe of the liver was administered 0.47 GBq (77.5 Gy), which was the intended dose for the anterior portion of the right lobe of the liver. The total dose to the right lobe of the liver (both posterior and anterior portions) was 0.90 GBq (142 Gy) compared to the planned dose of 0.91 GBq (143.6 Gy). Our color coding procedure failed to prevent this error. The radiopharmacy staff had applied the green colored dot to the QMP [Quality Management Program] and Dose Planning Forms appropriate for the posterior portion of the right lobe. The medical physicist applied the green colored dot to the checklist intended for the anterior portion of the right lobe rather than to the checklist intended for the posterior portion of the right lobe. The error was not caught during the time out prior to the dose administration. Upon completion of the first of the dual administrations, the medical physicist identified and reported the error to the authorized user and RSO. A time out was called and the decision was made to prepare a new Y-90 SIR-Sphere dosage for the anterior portion of the right lobe in accordance with the written directive. The correct dose was then administered in accordance with the written directive to the anterior portion of the right lobe of the liver (0.43 GBq and 53.4 Gy).
"To prevent this from occurring, the color coding procedure was revised by the Radiopharmacy and modeled after their blood labeling process. The check list was revised to instruct the medical physicist that 'If dual administration case, verify correct color dots on QMP form, dose plan, and checklist.' Before a dual administration case is started, the dose planning page with the correct corresponding color dot will be pulled from the paperwork and placed in the control room. This allows the AU [authorized user], physicist, and remaining team (techs, nurses) to see the plan clearly. Once the physician (AU) gains access to the first treatment site, they will give the verbal notice to the physicist, so they can assemble the corresponding dose. With the finished assembly in place table side, the AU and physicist will verify the dose intended for the location. As it pertains to this case, the physician would say, 'We are in the posterior right lobe, the dosage is 0.52 GBq and is labeled with the orange dot, correct?' The QMP was revised to include these revised procedures. No adverse effect is expected for the patient. Both the patient and the referring physician were notified on October 30, 2014."
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.
"This is a notification of a medical event that occurred on October 30, 2014 at 1000 EDT in which the Y-90 SIR-Sphere dose delivered to the patient's posterior portion of the right lobe of the liver was more than the prescribed dose by 20 percent or more (10 CFR 35.3045). This patient had a dual administration, with the correct dose administered in accordance with the written directive to the anterior portion of the right lobe of the liver (0.43 GBq and 53.4 Gy). The medical event occurred before this, when the patient who was prescribed a dose of 0.39 GBq (64.5 Gy) was administered a dose that was 20.5% more than the prescribed dose. The posterior portion of the right lobe of the liver was administered 0.47 GBq (77.5 Gy), which was the intended dose for the anterior portion of the right lobe of the liver. The total dose to the right lobe of the liver (both posterior and anterior portions) was 0.90 GBq (142 Gy) compared to the planned dose of 0.91 GBq (143.6 Gy). Our color coding procedure failed to prevent this error. The radiopharmacy staff had applied the green colored dot to the QMP [Quality Management Program] and Dose Planning Forms appropriate for the posterior portion of the right lobe. The medical physicist applied the green colored dot to the checklist intended for the anterior portion of the right lobe rather than to the checklist intended for the posterior portion of the right lobe. The error was not caught during the time out prior to the dose administration. Upon completion of the first of the dual administrations, the medical physicist identified and reported the error to the authorized user and RSO. A time out was called and the decision was made to prepare a new Y-90 SIR-Sphere dosage for the anterior portion of the right lobe in accordance with the written directive. The correct dose was then administered in accordance with the written directive to the anterior portion of the right lobe of the liver (0.43 GBq and 53.4 Gy).
"To prevent this from occurring, the color coding procedure was revised by the Radiopharmacy and modeled after their blood labeling process. The check list was revised to instruct the medical physicist that 'If dual administration case, verify correct color dots on QMP form, dose plan, and checklist.' Before a dual administration case is started, the dose planning page with the correct corresponding color dot will be pulled from the paperwork and placed in the control room. This allows the AU [authorized user], physicist, and remaining team (techs, nurses) to see the plan clearly. Once the physician (AU) gains access to the first treatment site, they will give the verbal notice to the physicist, so they can assemble the corresponding dose. With the finished assembly in place table side, the AU and physicist will verify the dose intended for the location. As it pertains to this case, the physician would say, 'We are in the posterior right lobe, the dosage is 0.52 GBq and is labeled with the orange dot, correct?' The QMP was revised to include these revised procedures. No adverse effect is expected for the patient. Both the patient and the referring physician were notified on October 30, 2014."
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.
Power Reactor
Event Number: 50580
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATTHEW ROBERTSON
HQ OPS Officer: MARK ABRAMOVITZ
Region: 2 State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATTHEW ROBERTSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/30/2014
Notification Time: 14:07 [ET]
Event Date: 10/30/2014
Event Time: 11:00 [EDT]
Last Update Date: 10/30/2014
Notification Time: 14:07 [ET]
Event Date: 10/30/2014
Event Time: 11:00 [EDT]
Last Update Date: 10/30/2014
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):
MARVIN SYKES (R2DO)
MARVIN SYKES (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 AND PRESS RELEASE REGARDING BOONE DAM STABILITY ISSUES
"On October 30, 2014, at 1100 EDT, TVA conducted a briefing for government officials and other stakeholders regarding the decision to accelerate the Boone Reservoir annual drawdown after discovery of a sink hole near the base of the embankment and a small amount of water and sediment found seeping from the river below the dam. TVA is continuously monitoring the dam and conducting an investigation to determine the source of the water seepage.
"The dam is located upstream of all three TVA nuclear sites. There are currently no nuclear plant operability or safety issues, and TVA is assessing the impacts on the plant licensing bases.
"A press release was issued at approximately 1300 EDT.
"This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi) due to notification of other government agencies and a news release.
"The NRC Senior Resident Inspector was notified."
The licensee is evaluating this event for potential impact on the design basis flooding level.
"On October 30, 2014, at 1100 EDT, TVA conducted a briefing for government officials and other stakeholders regarding the decision to accelerate the Boone Reservoir annual drawdown after discovery of a sink hole near the base of the embankment and a small amount of water and sediment found seeping from the river below the dam. TVA is continuously monitoring the dam and conducting an investigation to determine the source of the water seepage.
"The dam is located upstream of all three TVA nuclear sites. There are currently no nuclear plant operability or safety issues, and TVA is assessing the impacts on the plant licensing bases.
"A press release was issued at approximately 1300 EDT.
"This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi) due to notification of other government agencies and a news release.
"The NRC Senior Resident Inspector was notified."
The licensee is evaluating this event for potential impact on the design basis flooding level.
Power Reactor
Event Number: 50581
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TERRY DUNNY
HQ OPS Officer: HOWIE CROUCH
Region: 2 State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TERRY DUNNY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/30/2014
Notification Time: 12:48 [ET]
Event Date: 10/30/2014
Event Time: 12:20 [EDT]
Last Update Date: 10/30/2014
Notification Time: 12:48 [ET]
Event Date: 10/30/2014
Event Time: 12:20 [EDT]
Last Update Date: 10/30/2014
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):
MARVIN SYKES (R2DO)
MARVIN SYKES (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 REGARDING BOONE DAM STABILITY ISSUES
"On October 30, 2014, at 1100 EDT, TVA conducted a briefing for government officials and other stakeholders regarding the decision to accelerate the Boone Reservoir annual drawdown after discovery of a sink hole near the base of the embankment and a small amount of water and sediment found seeping from the river below the dam. TVA is continuously monitoring the dam and conducting an investigation to determine the source of the water seepage.
"The dam is located upstream of all three TVA nuclear sites. There are currently no nuclear plant operability or safety issues, and TVA is assessing the impacts on the plant licensing bases"
The licensee has notified the NRC Resident Inspector.
"On October 30, 2014, at 1100 EDT, TVA conducted a briefing for government officials and other stakeholders regarding the decision to accelerate the Boone Reservoir annual drawdown after discovery of a sink hole near the base of the embankment and a small amount of water and sediment found seeping from the river below the dam. TVA is continuously monitoring the dam and conducting an investigation to determine the source of the water seepage.
"The dam is located upstream of all three TVA nuclear sites. There are currently no nuclear plant operability or safety issues, and TVA is assessing the impacts on the plant licensing bases"
The licensee has notified the NRC Resident Inspector.
Power Reactor
Event Number: 50582
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TODD CHRISTENSEN
HQ OPS Officer: MARK ABRAMOVITZ
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TODD CHRISTENSEN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/30/2014
Notification Time: 14:35 [ET]
Event Date: 10/30/2014
Event Time: 11:00 [CDT]
Last Update Date: 10/30/2014
Notification Time: 14:35 [ET]
Event Date: 10/30/2014
Event Time: 11:00 [CDT]
Last Update Date: 10/30/2014
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):
MARVIN SYKES (R2DO)
MARVIN SYKES (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 17 | Power Operation | 17 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
OFFSITE NOTIFICATION AND PRESS RELEASE REGARDING BOONE DAM STABILITY ISSUES
"On October 30, 2014, at 1100 EDT, TVA conducted a briefing for government officials and other stakeholders regarding the decision to accelerate the Boone Reservoir annual drawdown after discovery of a sink hole near the base of the embankment and a small amount of water and sediment found seeping from the river below the dam. TVA is continuously monitoring the dam and conducting an investigation to determine the source of the water seepage.
"The dam is located upstream of all three TVA nuclear sites. There are currently no nuclear plant operability or safety issues, and TVA is assessing the impacts on the plant licensing bases.
"A press release was issued at approximately 1300 EDT.
"This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi) due to notification other government agencies and a news release.
"The NRC Senior Resident Inspector was notified."
"On October 30, 2014, at 1100 EDT, TVA conducted a briefing for government officials and other stakeholders regarding the decision to accelerate the Boone Reservoir annual drawdown after discovery of a sink hole near the base of the embankment and a small amount of water and sediment found seeping from the river below the dam. TVA is continuously monitoring the dam and conducting an investigation to determine the source of the water seepage.
"The dam is located upstream of all three TVA nuclear sites. There are currently no nuclear plant operability or safety issues, and TVA is assessing the impacts on the plant licensing bases.
"A press release was issued at approximately 1300 EDT.
"This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi) due to notification other government agencies and a news release.
"The NRC Senior Resident Inspector was notified."