Event Notification Report for August 07, 2013

LOSS OF POWER TO EMERGENCY SIRENS AND POWER TO EMERGENCY OPERATIONS FACILITY DUE TO SEVERE WEATHER

"At approximately 0100 (CDT) on 7 August, 2013, severe thunderstorms and high winds in the area resulted in a loss of power to the Point Beach Nuclear Plant (PBNP) Emergency Operations Facility (EOF) and to Alert and Notification System (ANS) sirens. Loss of ANS sirens resulted in a loss of greater than 50% of the Emergency Planning Zone (EPZ) population coverage [14 out of 22 lost]. Note: PBNP has installed a new siren system that is currently in operational acceptance testing and remained fully functional on backup battery power.

"During the loss of power to the EOF, station personnel verified that power remained available to the Alternate Emergency Operations Facility (AEOF). At approximately 0545 CDT, station personnel verified that power to the EOF was restored. Efforts are ongoing to restore power to sirens."

The licensee has notified State and local authorities and the NRC Resident Inspector.

See related EN #49247.

* * * UPDATE FROM JERRY STRHARSKY TO HOWIE CROUCH AT 1654 EDT ON 8/7/13 * * *

At 1525 CDT on 8/7/13, the licensee returned 9 of 14 emergency sirens to service which brings the percentage of population covered by the sirens below the reporting threshold.

The licensee has notified the NRC Resident Inspector. Notified R3DO (Lara).

LOSS OF POWER TO EMERGENCY SIRENS DUE TO SEVERE WEATHER

"On August 7, 2013, at 0345 [CDT], Kewaunee Power Station was notified that a loss of alert sirens impacting greater than 50% of the Emergency Planning Zone population are non-functional due to a loss of power. The sirens are used to provide a public prompt notification. The sirens lost are those that Point Beach Nuclear Power Plant takes primary responsibility. Power was lost to them during a severe thunderstorm and the expected out of service time is unknown at this time.

"This condition is being reported in accordance with 10CFR50.72(b)(3)(xiii) as an event that results in a major loss of emergency assessment capability.

"The NRC Resident Inspector has been notified."

See related EN #49246

* * * UPDATE FROM SCOTT CIESLEWICZ TO PETE SNYDER AT 1652 EDT ON 8/7/13 * * *

Most emergency sirens have been returned to service such that the lost coverage is now only 24%.

The licensee notified the NRC Resident Inspector. Notified R3DO (Lara).

AGREEMENT STATE - PATIENT RECEIVED 20% LOWER THAN I-131 PRESCRIBED DOSE

The following Georgia Agreement State report was received via email.

"Event Description: Patient was scheduled for an I-131 prescribed dose of 100-150mCi for the treatment of Thyroid Carcinoma. The patient instead was administered a dose that deviated 20% lower than the prescribed dose. This incident was reported to the [Georgia] State per Rule 391-3-17.05(115)(a)1.(i):

'A dose that differs from the prescribed dose by more than 0.05 Sv (5 rem) effective dose equivalent, 0.5 Sv (50 rem) to an organ or tissue, or 0.5 Sv (50 rem) shallow dose equivalent to the skin; and either (i) The total dose delivered differs from the prescribed dose by 20 percent or more.'"

The State will provide the corrective action information when provided by the licensee.

GA State Report ID: CTS 71850

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.

* * * UPDATE FROM TRAVIS CARTOSKI TO HOWIE CROUCH VIA EMAIL ON 8/20/13 AT 1240 EDT * * *

"A sodium iodine I-131 thyroid ablation treatment was ordered as a NaI I-131 whole body scan resulting in a patient receiving a diagnostic dose of 5 mCi of NaI (I-131) instead of the therapeutic dose of 50 mCi of NaI (I-131).

"Both the referring physician and the patient were also informed of the misadministration of the 5 mCi I-131 dose for the whole body scan on August 7, 2013 in light of the confirmed order for an I-131 thyroid ablation. The order verification process was reviewed with all involved staff members and an extensive review of the process was begun.

"Nuclear Medicine, like all diagnostic services, requires verification of the order for services. This verification must be in the form of a written order or an electronic authenticated order. On August 1, 2013 Piedmont Hospital Atlanta implemented EPIC, a new electronic medical record (EMR). The orders verification process changed a bit, because Piedmont Physician Groups could place an order within the EPIC environment (EPIC Physicians) and have them electronically authenticated, with e-signature and a time stamp. Physicians not in the EPIC environment (non-EPIC Physicians) could still schedule services through scheduling by providing a written order. Once scheduling had received a written order, the ancillary orders process would produce an order that looked just like the order produced by an EPIC physician, but the chart would have a paper clip to signify that it was a non-EPIC Physician order.

"During the first week of the EPIC implementation, many of the orders that were transcribed by the scheduling services department did not have the attachment of the original written order. This information came to light during the first few days of go-live but not all end users were informed on the issue. In this particular case, the patient's order was requested by a non-EPIC physician, as an I-131 whole body scan. The order was transcribed by scheduling , and as of August 7, 2013, the original order was not scanned into the chart. The order in the chart appeared to be an EPIC Physician order. Based on the information known at the time, the order for an I-131 whole body scan was verified and the patient was dosed and instructed to return on Friday August 9, 2013 for imaging.

"On August 8, 2013, a copy of the original order was scanned into the patient's record. The order contained more detailed information concerning the reason for the referral to nuclear medicine. This information would prove to be vital in determining the actual course of treatment requested by the referring physician.

"On Friday August 9, 2013, the patient returned for the whole body scan, but due to a downed system at the hospital the patient was referred to the Piedmont West Imaging Center to complete their test. While preparing the report template in PACs (Name removed), noticed that the patients chart had a paper clip icon but the documentation that she had received from the hospital Nuclear Medicine department only had an EPIC Physician order. (Name removed) opened the original scanned order for an I-131 whole body scan and discovered that within the comments section of the note that the Authorized User was referring the patient for an I-131 thyroid ablation. The office was contacted, and the order for an I-131 thyroid ablation was confirmed. (Name Removed), contacted the RSO to inform him of the events leading up to this misadministration.

"The actions taken to prevent a future reoccurrence of a similar event include:
-Training on the orders verification process in EPIC for all Nuclear Medicine staff members
-Defining the difference between an EPIC Physician order and a non-EPIC Physician order
-All non-EPIC Physician orders must have an attached copy of the original order or a call must be placed to the provider's office requesting a copy of the order if the patient does not have an original copy."

Notified R1DO (Schmidt) and FSME (via email).

AGREEMENT STATE REPORT - VENTILATION PERFUSION LUNG SCAN ADMINISTERED INSTEAD OF CT LUNG SCAN

The following event report was received from the State of Florida via facsimile:

"Received notification of a medical event on 15 Aug 2013 at 10:30 am [EDT] from Bayfront Medical Center, license number 4374-1. Date of procedure was 7 Aug 2013. A patient was prescribed a CT lung scan by the physician. Technologist entered, by mistake, Ventilation Perfusion Lung Scan into the computer (9 mCi's of Xenon-133). Patient's physician was notified, patient was on a ventilator and was not able to communicate. [This incident was] assigned to the Tampa Office for investigation. No further action will be taken on this incident."

Florida Incident Number: FL13-056

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.

NONCONFORMING WELDS RESULTING IN CRACKS IN HVAC FILTER HOUSING REPAIR WELDS

Summary of information received via fax:

The Shaw AREVA Mixed Oxide Fuel Fabrication Facility found nonconforming welds that resulted in cracks in HVAC filter housings supplied to MOX Services by Flanders. The filter housings are credited for the confinement of radioactive material. There is a possibility for additional material stresses to be placed on the subject filter housings which could cause the propagation and increase in size of the cracks. Because the cracks identified in the non-conformance report could propagate to an indeterminate size, the ability of the portions of the HDE system upstream of these filter housings to maintain the confinement boundary and perform its safety function cannot be determined. MOX Services will ensure repairs are performed by either the vendor, MOX Services, or a third party. These repairs will be performed in support of the construction schedule.

AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY DEVICE

The following was received from the State of Nevada via email:

"A radiography device was involved in a structural collapse at Barrick Goldstrike Mines, north of Carlin. A wind gust collapsed a steel tank and the scaffolding around it where a radiographer (met chem reciprocity) was working. The device fell approx. 60 ft., damaging the shutter end. The radiographer was not seriously injured and determined that the radiation source was secure and there was no leakage. He packaged the camera and returned to Utah."

Item Number: NV130013