Event Notification Report for January 23, 2018

LOSS OF ASSESSMENT CAPABILITY DUE TO TECHNICAL SUPPORT CENTER PLANNED MAINTENANCE

"At 0400 [CST] on 1/23/2018 the Braidwood Technical Support Center (TSC) HVAC [Heating, Ventilation and Air Conditioning] Emergency Makeup Air Filter train was taken out of service to perform a planned Makeup Air Filter charcoal replacement. The TSC HVAC Makeup Air Filter train will be rendered nonfunctional during the charcoal replacement. Subsequent charcoal and HEPA filter testing will restore functionality of the TSC HVAC Makeup Air Filter train. The expected duration of the charcoal replacement and subsequent testing is 30 hours.

"If an emergency is declared requiring TSC activation during the time TSC HVAC is non-functional, the TSC will be staffed and activated using existing emergency planning procedure unless the TSC becomes uninhabitable due to ambient temperature, radiological, or other conditions. If relocation of the TSC becomes necessary, the Emergency Director will relocate the TSC staff to an alternate location in accordance with applicable site procedures.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) due to a major loss of emergency preparedness capability. An update will be provided once the TSC HVAC Emergency Makeup Air Filter train functionality has been restored.

"The licensee has notified the NRC Resident Inspector."

AGREEMENT STATE REPORT - PATIENT RECEIVED DOSE LESS THAN PRESCRIBED DOSE

The following information was obtained from the state of Washington via email:

"Swedish Medical Center (SMC) reported that a patient prescribed to receive 725 MBq (19.59 mCi) of Y-90 microspheres (Sirtex Medical model SIR-Spheres) to the left lobe of the liver, only received 370 MBq (10 mCi). SMC planned a two-artery feed, using 360 MBq (9.73 mCi) per artery per sub lobe. The written directive called for a total of 725 MBq (19.59 mCi) split into two doses. The certified nuclear medicine technologist who drew the dose did not properly review the written directive's instruction to split the total dose into two doses. Instead, the technologist split 370 MBq (10 mCi) into two doses of 190 and 180 MBq (5.14 and 4.86 mCi), respectively. Prior to patient administration, the radiation oncologist also failed to check the drawn doses prior to injecting them. The incident was identified post-injection when the remaining 360 MBq (9.73 mCi) of the original 725 MBq (19.59 mCi) was discovered. The physicians involved believe that the diminished dose may still provide the treatment sought. They will follow up on the patient in six months and will, if deemed necessary, retreat the liver lesions. The referring physician and patient were informed of the incident. SMC's investigation identified several errors: lack of comprehension regarding the dose draw worksheet, miscommunication and failure to review the written directive prior to correcting a dose, and failure to perform a safety pause and properly review the dose to be administered against the written directive prior to administration. Corrective actions included modifying the dose draw spreadsheet, training the nuclear medicine department with regards to the spreadsheet, and modifying the treatment record sheet to include a formal procedural pause prior to administration. The Washington Department of Health, Office of Radiation Protection, did not anticipate conducting an onsite investigation."

NMED Item Number: 180058

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.