Event Notification Report for June 03, 2016

PATIENT ADMINISTERED THE WRONG BYPRODUCT MATERIAL

The following was received via email:

"This is a report and notification of a medical event for Perry County Memorial Hospital, located in Perryville, Missouri, which occurred today June 3, 2016 at approximately 7:30 a.m. CST. This medical event is being reported as required under 10 CFR Part 35.3045 (a)(2)(i), administration of a wrong radioactive drug containing byproduct material resulting in an effective dose equivalent of greater than 0.05 Sv or 5 rem.

"At approximately 8:15 a.m. today, [The Diagnostic Radiological Physicist] received a call from Perry County Memorial Hospital, that one of his nuclear medicine technologists had inadvertently administered a 63 y/o female patient a bulk unit dose of approximately 128 mCi of Tc-99m Sodium Pertechnetate intravenously. This female patient was scheduled to receive a 25 mCi dose of Tc-99m Medronate intravenously for bone scintigraphy. Using a Tc-99m Sodium Pertechnetate package insert provided by the unit dose supplier, [the Diagnostic Radiological Physicist] estimated that the resultant effective dose equivalent to the patient will be approximately 0.06 Sv or 6 rem. The resultant highest dose to any organ or tissue is estimated to be approximately 27 rads, which would be to the patient's upper lower intestinal wall.

"The patient has been notified with regards to this medical event. In addition, the RSO [Radiation Safety Officer] / Authorized User for Perry County Memorial Hospital has also been notified."

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.

PART 21 - NOTIFICATION OF DEVIATION OF K-LINE CIRCUIT BREAKER SECONDARY TRIP LATCH

The following was excepted from a report from ABB, Inc. via email:

"This letter provides notification of a defect associated with the secondary trip latch, P/N: 716789E00, which is used in the 167710T01 & 167710T03 secondary latch bar assembly and assembly kit, respectively. These assemblies are used in low voltage K-Line 225-800 Amp and 1600-2000 Amp circuit breakers. The reported failure was caused by the pin in the secondary trip latch that the return spring attaches to not being installed properly. The pin hit the tab on the tripper bar when the latch returned to the reset position. This caused the breaker to trip open. This failure was reported by Xcel Energy Prairie Island Nuclear Plant and it is the only reported occurrence of a failure caused by the return spring pin being out of position. The secondary trip latch has been cast by the same since 1996. No other field failures or failures in the ABB Service facilities have been reported as a result of this pin being out of position. Information is provided as specified in 10CFR21 paragraph 21.21(d)(4).

"Notifying individual: Andrew Wall, Vice President & General Manager, ABB (Electrification Products Medium Voltage Service US), 2300 Mechanicsville Road, Florence, SC 29501

"Identification of the Subject component: ABB part numbers 716789E00 (secondary latch bar) and 167710T01 & 167710T03 (secondary latch bar assemblies). The secondary latch bar is available as an individual component and the secondary latch bar assemblies are utilized as components, as part of refurbishment kits, in K-Line operating mechanisms, in new K-Line breakers, and they may be replaced during a K-Line breaker refurbishment.

"Nature of the deviation: The pin that holds the return spring in place was not properly installed. The defect is believed to have occurred during the assembly process of the latch bar. The latch used in the Prairie Island Nuclear Plant circuit breaker was fabricated in 2013.

"Corrective actions include:
Quarantined and inspected PIN: 716789E00 and 167710T01/167710T03 assemblies in inventory. (Action complete)
Notified vendor of the issue via the ABB Supplier Corrective Action Request process. (Action complete)
Revised Critical Characteristic card for PIN: 716789E00 to incorporate measurement of the pin in question. (Action complete)
Conducted training with QA and Operations personnel for awareness (Action complete)

"Recommendations:
Because of the large potential variety of usages of the potentially affected circuit breakers, ABB (Medium Voltage Service) cannot determine if the potential for a substantial safety hazard exists at any licensee's facility if the circuit breaker fails to operate. It is recommended the Licensees inspect the in-service components at the next convenient maintenance opportunity and components in stock prior to installation. The pin should protrude 0.26 ( +/- 0.02) inches out of both sides of the section of the latch bar assembly.
If the latch is installed on a K-Line circuit breaker, the latch can be inspected from the bottom side of the mechanism without disassembly.

"Questions concerning this notification should be directed to the Quality Manager at the Medium Voltage Service Center in Florence, SC at (843) 413-4782 or Fax (843) 413-4853."

HOO Note: See EN #51975 for Part 21 received from Prairie Island Nuclear Generating Station.

LOSS OF GENERAL LICENSED MATERIAL CHECK SOURCES

On June 3, 2016, the US Air Force determined that two (2) check sources containing Thorium-232 (45 nCi and 13 nCi) were missing at the Aviano Air Base located in Italy. These two generally licensed sources are used as check sources for the ADM-300 survey meter.

The licensee contacted NRC RIV (Michelle Simmons) who recommended that the licensee report the loss per 10 CFR 31.5(c)(10).

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf