Event Notification Report for September 11, 2019

AGREEMENT STATE REPORT - MISADMINISTRATION OF HIGH DOSE RATE THERAPY

The following was received via email from the Massachusetts Department of Public Health - Radiation Control Program (the Agency):

"On 09/13/19, a medical event was reported by Massachusetts General Hospital (MGH) (the licensee) involving the medical misadministration of HDR [high dose rate] therapy. The 59 year-old patient involved received dose to unintended tissue exceeding 50 percent of the prescribed dose defined in the written directive. The prescribed dose was 5.5 Gy over 5 fractions for a total of 27.5 Gy to the cervix. The therapy was performed using a Syeb-Neblett Template and 6 catheters including 1 tandem. The patient ultimately received the full intended dose to the tumor (high risk- CTV [clinical target volume]) and per the licensee there was no overdose to any critical structures including bladder, rectum, or bowel. A small region of the surface of the right vaginal wall (approximately 1 cm) did inadvertently receive 16.5 Gy due to the wrong treatment distances being entered into the treatment planning system for 2 of the 7 catheters by the physicist. The patient is not expected to be at an increased risk for toxicity due to this error. Both the patient and referring physician were immediately notified upon discovery. Licensee to submit written report within 15 days of discovery date. The Agency considers this event to be open and pending investigation."

Event Docket # 21-3895
NMED # 190464

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.

MEDICAL EVENT - PALLADIUM-103 SEEDS IMPLANTED TO WRONG TARGET AREA

The following information was received from the Texas Department of State Health Services via E-mail:

"On September 11, 2019, the Agency [Texas Department of State Health Services] was notified that the licensee had identified that a medical event had occurred at its facility. The licensee reported it had discovered that the 52 palladium-103 seeds (1.292 mCi each) that had been implanted into a patient on August 1, 2019, which were intended to deliver 100 gray to the prostate, were all inferior to the patient's prostate approximately four centimeters.

"The licensee has notified the referring physician and patient. The licensee stated the current plan is to implant the prostate. There are no significant adverse effects expected.

"An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

* * * UPDATE RECEIVED FROM ART TUCKER TO OSSY FONT ON 09/13/19 AT 1752 EDT * * *

"On September 13, 2019, the Agency received additional information on this event. The licensee's report stated that on August 1, 2019, the physician was using ultrasound imaging to locate the prostate [and] misidentified the penile bulb as the prostate. The licensee stated this occurred because the penile bulb was very similar in size (10.8 cc versus 12 cc for the prostate) and they were very close to each other. As a result, 52, 1.292 milliCurie (67.2 milliCurie total) Palladium-103 seeds were placed four centimeters inferior to the prostate. The error was not discovered until September 11, 2019 during the post-implant dosimetry review.

"The estimated exposure to 90 percent of the penile bulb is 73 gray. The report stated that the patient is elderly and not sexually active; therefore, there is no increased risk of erectile dysfunction. The licensee identified the urethral structure as additional tissue at risk, but expected the effects to be the same as if the seeds had been properly placed at the prostate. The estimated dose to the prostate was 0 gray. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: I-9710

Notified R4DO (Alexander) and NMSS Events Notification E-mail group.

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.

OFFSITE NOTIFICATION DUE TO WASTE TREATMENT LAGOON DISCHARGE TO THE SOIL

"In preparation for Hurricane Dorian, the Waste Treatment Operator in Responsible Charge (ORC) decided to lower the level in the Waste Treatment Central Lagoon by treating and transferring to Process Lagoons. Piping was damaged and not noticed during a walkdown prior to pumping from waste treatment to the process lagoons. This resulted in water being discharged to the soil.

"Upon discovery, the water was contained and sampled. Sample results were all below regulatory limits. The pipe was repaired. The NPDES permit requires a report to North Carolina Division of Water Resources (NC DWR). This report was made at 10:01 am on 9/11/2019. Because NC DWR was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."

The Licensee will be notifying the Region II office.

FITNESS-FOR-DUTY REPORT INVOLVING A CONTRACT SUPERVISOR

A non-licensed contract supervisor had a confirmed positive for illegal drugs during a random fitness-for-duty test. The individual's authorization for site access has been terminated.

The NRC Resident Inspector has been notified.

LOST / STOLEN TRITIUM EXIT SIGN

The following information was received from the Arizona Department of Health Services via E-mail:

"The Department [Arizona Department of Health Services] received notification that a tritium exit sign has been lost/stolen. The model is an Isolite 2040 with an activity of approximately 7.5 curies. The Department has requested additional information and continues to investigate the event."

Arizona Incident Number: 19-018

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

PRIMARY CONTAINMENT AIRLOCK DOOR NOT IN FULLY SEATED POSITION

"On September 11, 2019 at 1719 CDT, plant personnel identified a condition in which the 208 foot elevation inner primary containment airlock door was not in its fully seated and latched position while the 208 foot elevation outer primary containment airlock door was opened. The 208 foot elevation outer containment airlock door was subsequently closed by the individual exiting the area. The time that both 208 foot elevation containment airlock doors were not in their fully seated and latched positions was less than 1 minute. Following this occurrence, maintenance personnel inspected the 208 foot elevation inner containment airlock door and re-positioned this door to its fully seated and latched position. There was no radioactive release as a result of this event.

"This condition requires an 8-hour non-emergency notification in accordance with 10CFR50.72(b)(3)(v)(C) as an event or condition that could have prevented fulfillment of a safety function needed to control the release of radioactive material.

"The NRC Resident Inspector has been notified."

MAIN STEAM LINE RADIATION MONITOR COMMUNICATION FAILURE

"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"Radiation monitor RU-140 (#2 Steam Generator Main Steam Line radiation monitor) experienced a communication failure on both ports A and B. The RU-140 monitor is off line and non-functional at this time.

"At least one channel of RU-140 is required to perform a Steam Generator Tube Rupture (SGTR) dose assessment. This represents an unplanned loss of radiological assessment capability for the inability to perform dose assessments that require the radiation monitor. The ability to make emergency classifications from other radiological data collection methods such as field sampling remains available. Actions have been initiated to restore the radiation monitor.

"The NRC Resident Inspector has been informed."