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Event Notification Report for February 27, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/26/2015 - 02/27/2015

** EVENT NUMBERS **


50785 50832 50833 50834 50851

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 50785
Rep Org: IU HEALTH BALL MEMORIAL HOSPITAL
Licensee: IU HEALTH BALL MEMORIAL HOSPITAL
Region: 3
City: MUNCIE State: IN
County: DELAWARE
License #: 13-00951-03
Agreement: N
Docket:
NRC Notified By: ALVIS FOSTER
HQ OPS Officer: DANIEL MILLS
Notification Date: 02/04/2015
Notification Time: 17:23 [ET]
Event Date: 01/15/2014
Event Time: [EST]
Last Update Date: 02/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
LAURA KOZAK (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

INERT CAPSULE ADMINISTERED TO PATIENT DURING TREATMENT

The following was received from the licensee via email:

"A 40 year old adult male patient was scheduled to receive 150 mCi of radioactive Iodine 131 as a thyroid cancer therapy. The dose, in pill form, was assayed as prescribed on Wednesday 1/15/14 and was believed to have been [administered to the patient].

"On 1/23/14, the patient returned for a whole body scan, [which is] a routine part of the procedure. After scanning the patient, it was noted that there was no activity remaining, which could not be possible under normal circumstances, because Iodine 131 has an 8 day physical half-life. Even with biological excretion occurring, one would expect significant detectable activity 8 days after administration.

"Two technologists were involved, one assayed the dose and put it back in temporary storage, the other subsequently retrieved the capsule and administered it. Upon investigation it was found that an inert capsule was inadvertently retrieved rather than the patient's capsule. The capsule the patient should have received was discovered and assayed, and found to be the actual capsule that should have been delivered.

"The tablet given to the patient had an activity of 30 mCi of Iodine 131 on 8/2/13, this was some 20 half-lives prior to the January 2014 date of this incident and [the capsule] was therefore completely inert, therefore no dose was administered.

"[The licensee] talked with [the licensee's] Nuclear Medicine consultant, to review the regulations. Upon review of USNRC regulations and based upon advice from [the consultant], this was not deemed a medical event but rather a self-identified violation of our procedures.

"Based upon an NRC review during an inspection on 2/3/15 we were advised that this occurrence, in [the NRC inspector's] opinion, constitutes a Medical Event based on Title 10 of the Code of Federal Regulations Part 35.3045.

"We were advised to contact the USNRC offices in Region III by the end of business on 2/4/15 and report the occurrence as a Medical Event.

"With respect to patient impact, papillary/follicular cancers are slowing grow and indolent, and a delay in treatment would not be expected to adversely affect the outcome. The patient was subsequently rescheduled and administered the [prescribed] dose of Iodine 131.

"In order to determine cause and institute corrective measures, a root cause analysis investigation was conducted and as a result, procedure revisions were implemented to prevent the likelihood of additional errors of this type."

* * * RETRACTION FROM ALVIS FOSTER TO CHARLES TEAL AT 1558 EST ON 2/26/15 * * *

Since the patient received no dose as a result of this procedure, it was determined that this event was not a medical event.

Notified R3DO (Stone) and NMSS Events Notification via 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.

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Agreement State Event Number: 50832
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: TUFTS MEDICAL CENTER
Region: 1
City: BOSTON State: MA
County:
License #: 68-0263
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/19/2015
Notification Time: 10:15 [ET]
Event Date: 02/10/2012
Event Time: [EST]
Last Update Date: 02/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL OVERDOSE

The following report was received via e-mail:

"During a routine inspection, an Agency [Massachusetts Radiation Control Program] inspector identified a past possible gamma stereotactic radiosurgery (GSR also known as gamma knife) medical event that occurred on February 10, 2012 and had not been reported by the licensee.

"The licensee's written directive was incomplete. Page three of the written directive that described plug placement in the helmet used for treatment was not printed. As a result of the missing information, sixteen gamma knife plugs were not placed in position as intended and instead collimators were placed, the same size collimators used for the remaining plug pattern. Consequently, the patient received an 8.8% overdose to the treatment site. Based on the initial exposure determination to the treatment site by the licensee, the licensee concluded this was not a reportable medical event.

"However, the dose to tissue other than the treatment site exceeded 0.5 Sv (50 rem) and 50% of the dose expected from the administration defined in the written directive. This is a reportable medical event in accordance with 105 CMR 120.594(A)(1)(c).

"The dose to tissue other than the treatment site, tissue located beneath the skin and each of the sixteen collimators was calculated to be 71 rem, and greater than 50% of the dose expected from the administration. The dose expected to the tissue, tissue beneath the skin other than the treatment site from the administration defined in the written directive was expected to be less than 710 mrem.

"The gamma knife, a Leksell Gamma System model 24001 Type C device contained 201 Elekta model 43685 sealed sources totaling approximately 2,519 total curies of cobalt-60 on the date of the event, February 10, 2012.

"The licensee reported that the authorized user determined that the plug omission error would have no significant detrimental effect on the outcome of the treatment or patient condition and that no further action was necessary in the care of the patient. The licensee reported that that the authorized user reported the event in detail to the patient and provided a written description to the referring physician.

"The Agency issued notice of violations to the licensee and the licensee described its corrective actions in its response to the notice of violations.

"Corrective action: The licensee reported that following the omission of the plugs, the Radiation Oncologist Authorized User would designate on page 1 of the written directive if plugs were used and that this would alert the treatment team to identify and implement the appropriate plug pattern; that the licensee replaced the model 24001 Type C gamma knife with a model Perfexion gamma knife that does not use plugs; and that written directive printouts now contain both the individual page number and the total number of pages in the written directive."

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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Non-Agreement State Event Number: 50833
Rep Org: DEPARTMENT OF VETERANS AFFAIRS
Licensee: DEPARTMENT OF VETERANS AFFAIRS
Region: 4
City: NORTH LITTLE ROCK State: AR
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: THOMAS HUSTON
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/19/2015
Notification Time: 15:40 [ET]
Event Date: 12/29/2014
Event Time: [CST]
Last Update Date: 02/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

MEDICAL EVENT - UNDERDOSE

"This is a notification, pursuant to 10 CFR 35.3045(a)(1), of a medical event that occurred at the VA Medical Center, Durham, North Carolina.

"On December 29, 2014, a dosage of 1.569 millicuries of I-131 sodium iodide was administered to a patient for a diagnostic whole body scan, and the prescribed dosage on the written directive was 2 millicuries.

"The basis for identifying this as a medical event is that the administered dosage differed from the prescribed dosage by more than 20 percent and the absorbed dose is estimated to differ from that dose that would have resulted from the prescribed dose by more than 50 rem to remnant thyroid tissue.

"The medical event was discovered today (February 19, 2015) during a routine audit by the facility Radiation Safety Officer. The facility has notified the referring physician and the patient of the medical event. No biological harm to the patient is expected from this under-dosing event.

"The NHPP [National Health Physics Program] plans to perform a reactive inspection regarding the medical event within the next 10 working days. A 15-day written report for the medical event will be submitted to NRC Region III. National Health Physics Program notified NRC Region III (Patricia Pelke, Chief, Materials Licensing Branch Chief) of the medical event by telephone.

"Additional information: The Department of Veterans Affairs holds NRC License No. 03-23853-01VA, a master materials license. Permits are issued under the license to Veterans Health Administration facilities. The VHA permit number for the facility involved in this medical event is 32-01134-01. National Health Physics Program makes required notifications to NRC."


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: 50834
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: EQUISTAR CHEMICAL
Region: 4
City: DEER PARK State: TX
County:
License #: L00204
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/19/2015
Notification Time: 17:35 [ET]
Event Date: 02/19/2015
Event Time: [CST]
Last Update Date: 02/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - UNABLE TO CLOSE SHUTTER ON NUCLEAR GAUGE

The following information was received from the Texas Department of State Health Services via email:

"On February 19, 2015, the Agency [Texas Department of State Health Services] was notified by the licensee's Radiation Safety Officer (RSO) that during routine gauge testing, they were unable to close the shutter on a nuclear gauge. The gauge is an Ohmart model SHLG-2 containing 8,000 millicuries of cesium-137. The RSO stated the gauge is used for level indication on a vessel and open is the normal operating position for the gauge. The RSO stated the gauge does not present an increased exposure risk to their employees or members of the general public. The RSO stated they had lubricated the gauge operating mechanism in an attempt to free up the shutter, but the shutter remained stuck. The RSO stated they intend to contact the manufacturer for repairs to the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I 9280

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Power Reactor Event Number: 50851
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: PAGE KEMP
HQ OPS Officer: CHARLES TEAL
Notification Date: 02/26/2015
Notification Time: 16:39 [ET]
Event Date: 02/26/2015
Event Time: 15:11 [EST]
Last Update Date: 02/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
DEBORAH SEYMOUR (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 95 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO FEEDWATER REGULATING VALVE FAILING CLOSED

"On February 26, 2015, at 1511 EST, with Unit 1 operating at 95% power in an end of cycle coastdown, the 'B' Main Feedwater Reg Valve failed closed which resulted in a Unit 1 automatic reactor trip due to 'B' Steam Generator low/low level. The operations crew entered the reactor trip procedure and stabilized Unit 1 in Mode 3 at normal operating pressure and temperature. All control rods fully inserted into the core following the reactor trip. This reactor protection system actuation is reportable per 10CFR50.72(b)(2)(iv)(B). The Auxiliary Feedwater pumps actuated as designed as a result of the reactor trip and provided makeup flow to the steam generators. The automatic start of the Auxiliary Feedwater system is reportable per 10CFR50.72(b)(3)(iv)(A) for the valid actuation of an ESF system. The Auxiliary Feedwater pumps were subsequently secured and returned to automatic. Decay heat is being removed by the condenser steam dump system. Unit 1 is in a normal shutdown electrical lineup.

"The NRC Resident Inspectors have been notified and are in the Control Room. The Louisa County Administrator will be notified."

Page Last Reviewed/Updated Friday, February 27, 2015
Friday, February 27, 2015