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Event Notification Report for September 27, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/26/2013 - 09/27/2013

** EVENT NUMBERS **


49354 49360 49387

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Agreement State Event Number: 49354
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: MASSACHUSETTS GENERAL HOSPITAL
Region: 1
City: BOSTON State: MA
County:
License #: 60-0055
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: PETE SNYDER
Notification Date: 09/18/2013
Notification Time: 16:28 [ET]
Event Date: 09/18/2013
Event Time: [EDT]
Last Update Date: 09/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT'S LIVER

The Commonwealth of Massachusetts submitted the following information via email:

"A dose that likely differs from the prescribed dose by more than 50 rem to an organ, the liver, and the total dose delivered differs from the prescribed dose by 20% or more.

"The licensee's radiation safety officer reported to the Agency [Massachusetts Radiation Control Program] on 9/18/2013 that on same date licensee administered yttrium-90 SIR-Spheres to patient's left lobe of liver for treatment of metastatic disease; that 16.8 millicuries of yttrium-90 was prescribed; and that 12.06 millicuries was administered resulting in an under dose of 28.1 percent.

"The licensee discovered the event upon measurement of waste material including dose vial as part of normal quality assurance.

"The licensee's radiation safety officer reported that the authorized user and the referring physician have been notified and it is unknown at time of the report whether the referring physician has elected to notify the patient.

"The licensee's radiation safety officer reported that medical staff does not believe that this error will adversely affect the patient treatment outcome.

"The licensee will submit a written report within 15 days in accordance with the [Massachusetts] requirements of 105 CMR 120.594(A)(4) to include why event occurred and actions to prevent recurrence.

"Root cause and corrective action are not known at this time and the Agency continues to investigate.

"System Name: Brachytherapy Product; Manufacturer: Sirtex Wilmington LLC"

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.

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Agreement State Event Number: 49360
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: B & J PARTNERSHIP
Region: 4
City: LINCOLN State: NE
County:
License #: GL0747
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: CHARLES TEAL
Notification Date: 09/19/2013
Notification Time: 14:56 [ET]
Event Date: 06/25/2013
Event Time: [CDT]
Last Update Date: 09/19/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENT RESOURCE (EMAI)
DENNIS ALLSTON (ILTA)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following was received from the State of Nebraska via facsimile:

"B & J Partnership purchased two Isolite model SLX60 exit signs with 6.2 curies of H3 in each sign on December 8, 2011. On September 19, 2013 the Department [Nebraska Department of Health and Human Services] was notified that the General Licensee did not know where the exit signs were after an extensive search."

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

THIS MATERIAL EVENT CONTAINS A "NOT RECORDED" LEVEL OF RADIOACTIVE MATERIAL


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Power Reactor Event Number: 49387
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: STEVE INGALLS
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/26/2013
Notification Time: 20:12 [ET]
Event Date: 09/26/2013
Event Time: 12:20 [CDT]
Last Update Date: 09/26/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
BILLY DICKSON (R3DO)

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 N 0 Refueling 0 Refueling

Event Text

FITNESS FOR DUTY PROGRAM MEMBER IN VIOLATION OF POLICY

A Fitness For Duty (FFD) program member was in violation of the Northern States Power Company - Minnesota Nuclear FFD policy. The program member's access has been suspended pending assessment and management review.

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, September 27, 2013
Friday, September 27, 2013