Event Notification Report for September 21, 2018

AGREEMENT STATE REPORT - POTENTIAL LOSS OF I-125 SEED

The following was received by the State of Florida by email:

"[Boca Raton Regional Hospital Women's Imaging Center] Radiation Safety Officer, contacted [the State of Florida Bureau of Radiation Control] by phone on Friday, September 21, 2018 at approximately 1500 EDT to report the potential loss of a 170 microCurie Iodine-125 seed, from Boca Raton Regional Hospital Women's Imaging Center. ISOAID Seed Company has been contacted to assure the seed was not received in an earlier shipment. Seed can be tracked to the Nuc Med Hot lab. Staff has confirmed it is not in the patient or in the Pathology lab. Sealed source certificate will be sent later. Full investigation report will be submitted within 30 days."

Florida Incident Number: FL18-124

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

POSSIBLE EXTRAVASATION OF RA-223

"The patient's first dose of 110.3 microCuries, 4.3 mL, of Ra-223 (Xofigo) was administered today, 9/21/18 at 1040 CDT. An IV was placed by RN [Registered Nurse] in the patient's left wrist. The IV was flushed with saline and blood return was checked and present prior to administration of Ra-223 by [the] MD [medical doctor]. The Ra-223 was delivered by MD. After delivery, the MD began [a] saline flush and after approximately 5cc of saline, noted resistance and a cold bulge near the infusion site. He was not able to get blood return. The RN was called in to check the IV and was not able to get blood return. It was noted an infiltration/extravasation had occurred. The IV was removed with catheter noted to be intact. Prior to the infusion the patient was told that the infusion should not be painful and he did not acknowledge any pain or discomfort during or after infusion. At this time it is not known if there was an extravasation of Ra-223 because the infiltration/extravasation was not noted until during the second saline flush. The patient and patient's family were notified at the time of the incident."

* * * RETRACTION ON 10/03/18 AT 1525 EDT FROM TOM MOENSTER TO RICHARD SMITH * * *

The licensee does not believe there was more than 10 percent of therapy dose that was not infiltrated. Based on the fact that the swelling went down in less than 45 minutes post imaging of the wrist, compared to the body, leads the Radiation Safety Officer (RSO) to believe most of the therapy dose went throughout the body.

Notified R3DO (Orth) and NMSS vis email.

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.

HIGH PRESSURE COOLANT INJECTION SYSTEM INOPERABLE

"On 9/21/18, at 1755 EDT, Peach Bottom Atomic Power Station Unit 3 declared the High Pressure Coolant Injection system [HPCI] inoperable due to an inoperable differential pressure indicating switch [DPIS]. The DPIS is used to isolate the HPCI system when there is a high steam line flow condition. Operations declared the HPCI system inoperable and entered Technical Specification 3.5.1 Condition C for HPCI being inoperable. Technical Specification 3.3.6.1 was also entered for HPCI instrumentation being inoperable. Other standby systems (Reactor Core Isolation Cooling and Low Pressure Emergency Core Cooling Systems) are OPERABLE.

"HPCI is a single train system. Therefore, per NUREG-1022, this condition is being reported pursuant to 10CFR 50.72(b)(3)(v)(D) as a condition that could have prevented the fulfillment of the safety function of a system required to mitigate the consequences of a design event.

"This condition has been entered into the corrective action program (IR 4175355). Investigation of the exact cause of the indication issue is in progress.

"The NRC Resident has been informed of this notification."

* * * UPDATE AT 1317 EDT ON 09/22/2018 FROM CRAIG TAULMAN TO JEFF HERRERA * * *

"On 09/22/18 at 0955 EDT, RCS [Reactor Coolant System] pressure boundary leakage was identified as the cause of the HPCI high steam flow indication issue. Technical Specification 3.4.4 was entered which will require the initiation of a nuclear plant shutdown. This indicates a degradation of a principal safety barrier. Current Unit 3 reactor power is 35%. This condition is being reported pursuant to 10 CFR 50.72(b)(2)(i) and 50.72(b)(3)(ii). This condition is being tracked in the corrective action program (IR 4175355). The NRC Resident has been informed".

Peach Bottom will be notifying State and local agencies regarding the event.

Notified the R1DO (Greives).