Event Notification Report for September 09, 2011
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/08/2011 - 09/09/2011
Agreement State
Event Number: 47266
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: MD ANDERSON CANCER CENTER
Region: 4
City: HOUSTON State: TX
County:
License #: L00466
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: STEVE SANDIN
Licensee: MD ANDERSON CANCER CENTER
Region: 4
City: HOUSTON State: TX
County:
License #: L00466
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/14/2011
Notification Time: 15:03 [ET]
Event Date: 09/09/2011
Event Time: 18:00 [CDT]
Last Update Date: 09/14/2011
Notification Time: 15:03 [ET]
Event Date: 09/09/2011
Event Time: 18:00 [CDT]
Last Update Date: 09/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GREG PICK (R4DO)
ADELAIDE GIANTELLI (FSME)
GREG PICK (R4DO)
ADELAIDE GIANTELLI (FSME)
AGREEMENT STATE REPORT INVOLVING A LESS THAN PRESCRIBED DOSE ADMINISTRATION
The following information was received from the State of Texas via email:
"On September 13, 2011, the Agency was notified by the licensee that it had determined that a medical event had occurred at its facility. The licensee reported that on Friday, September 9, 2011, a patient had undergone a therapy procedure at approximately 3:00 p.m. which involved insertion of Yttrium-90 TheraSpheres into the liver. The patient's prescribed dose was to be 80 gray. Following the procedure, the technician took measurements, as part of the standard operating procedures, of the vial and other items associated with the treatment. The technician found that the dose rate was higher than would be expected if all of the contents of the vial had been delivered. The technician notified the medical physicist and they discussed the measurements. At approximately 6:00 p.m. they determined that an underdose had most likely occurred, but they were not yet sure it was a medical event. On Monday, September 12th, evaluation and measurements were conducted on the vial and dose calculations were completed. On Monday afternoon, it was determined that the patient had received a dose of 49 gray (22.3 millicuries administered), which is 39% less than the prescribed dose of 80 gray (37 millicuries). A meeting was arranged with the facility's Radiation Safety Officer on Tuesday, September 13th, at which time he was advised of the findings. Initial investigation by the licensee indicated some type of failure of the septum on the TheraSphere vial had occurred. The licensee will complete their investigation and submit a written report. An update to this report will be provided when new information is received."
Texas Incident No.: I-8883
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.
The following information was received from the State of Texas via email:
"On September 13, 2011, the Agency was notified by the licensee that it had determined that a medical event had occurred at its facility. The licensee reported that on Friday, September 9, 2011, a patient had undergone a therapy procedure at approximately 3:00 p.m. which involved insertion of Yttrium-90 TheraSpheres into the liver. The patient's prescribed dose was to be 80 gray. Following the procedure, the technician took measurements, as part of the standard operating procedures, of the vial and other items associated with the treatment. The technician found that the dose rate was higher than would be expected if all of the contents of the vial had been delivered. The technician notified the medical physicist and they discussed the measurements. At approximately 6:00 p.m. they determined that an underdose had most likely occurred, but they were not yet sure it was a medical event. On Monday, September 12th, evaluation and measurements were conducted on the vial and dose calculations were completed. On Monday afternoon, it was determined that the patient had received a dose of 49 gray (22.3 millicuries administered), which is 39% less than the prescribed dose of 80 gray (37 millicuries). A meeting was arranged with the facility's Radiation Safety Officer on Tuesday, September 13th, at which time he was advised of the findings. Initial investigation by the licensee indicated some type of failure of the septum on the TheraSphere vial had occurred. The licensee will complete their investigation and submit a written report. An update to this report will be provided when new information is received."
Texas Incident No.: I-8883
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: 47253
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: TIM LOVE
HQ OPS Officer: VINCE KLCO
Region: 1 State: MD
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: TIM LOVE
HQ OPS Officer: VINCE KLCO
Notification Date: 09/09/2011
Notification Time: 14:01 [ET]
Event Date: 09/09/2011
Event Time: 00:00 [EDT]
Last Update Date: 09/09/2011
Notification Time: 14:01 [ET]
Event Date: 09/09/2011
Event Time: 00:00 [EDT]
Last Update Date: 09/09/2011
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):
TODD JACKSON (R1DO)
TODD JACKSON (R1DO)
| 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 DUE TO LEAKING A SMALL QUANTITY OF DIESEL FUEL OIL
"A temporary diesel generator has emitted droplets of oil to the ground which was washed to a storm drain. The exhaust droplets were contained in secondary containment. An oil-only absorbent boom was placed around the storm drain to capture residual oil and prevent oil to the storm drain."
It is estimated that 0.05 gallons of diesel fuel entered a storm drain.
The licensee notified the Maryland Department of Environment, National Response Center, U.S. Coast Guard and the NRC Resident Inspector.
"A temporary diesel generator has emitted droplets of oil to the ground which was washed to a storm drain. The exhaust droplets were contained in secondary containment. An oil-only absorbent boom was placed around the storm drain to capture residual oil and prevent oil to the storm drain."
It is estimated that 0.05 gallons of diesel fuel entered a storm drain.
The licensee notified the Maryland Department of Environment, National Response Center, U.S. Coast Guard and the NRC Resident Inspector.