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Event Notification Report for August 17, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/14/2015 - 08/17/2015

** EVENT NUMBERS **


51292 51299 51321

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Agreement State Event Number: 51292
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: VIDANT MEDICAL CENTER
Region: 1
City: GREENVILLE State: NC
County:
License #: 074-1457-1
Agreement: Y
Docket:
NRC Notified By: DAVID CROWLEY
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/06/2015
Notification Time: 12:22 [ET]
Event Date: 08/05/2015
Event Time: [EDT]
Last Update Date: 08/06/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO ADMINISTRATION OF HIGHER DOSE THAN PRESCRIBED

The following information was provided by the State of North Carolina via email:

"Pitt County Memorial Hospital, Inc. dba Vidant Medical Center (License No. 074-1457-1) had a medical event occur yesterday afternoon [08/05/2015]. In brief, a patient with a low GFR [Glomerular Filtration Rate] was being treated for thyroid carcinoma. The original plan was to give the patient 50 mCi of I-131, which was received, assayed and ready for the Radiologist's approval.

"The Radiologist on site was not the original Radiologist who planned the treatment for this patient. The physician onsite felt that with the low GFR (score to indicate kidney function) a lower dose, 35 mCi, would be prudent and a second order was placed with the radiopharmacy.

"Around 1200 EDT, the dose was received, assayed and ready for administration. The Radiation Safety Representative identified the patient as required and discussed the home-going instructions with the patient prior to the administration. After the patient acknowledged the instructions, the Radiation Safety Representative went to the hot lab, confirmed the written directive, identified an assayed dose with the patient's name on it (of which there were two), failed to confirm the activity on the pig and slip, and administered the dose.

"The error was not identified until the hot lab nuclear medicine technologist noted that the 35 mCi dose was still in the hot lab. The Radiologist and Radiation Safety Office was notified immediately. As of 1420 EDT, the referring physician was notified and patient was to be notified by the end of the day. At this time, it is not probable that there will be any health impact from the discrepancy.

"A NC Health Physicist will be doing a reactive inspection before the end of this week. The radiation safety team is conducting an investigation and will be filing a formal report (15-day report) by August 20, 2015."

NC NMED Report Identification number: NC150023


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: 51299
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: WELLSTAR KENNESTONE HOSPITAL
Region: 1
City: MARIETTA State: GA
County:
License #: GA 328-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/07/2015
Notification Time: 15:58 [ET]
Event Date: 08/05/2015
Event Time: [EDT]
Last Update Date: 08/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

GEORGIA AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO OVEREXPOSURE

The following information was provided by the State of Georgia via email:

"The [Georgia] Radioactive Materials Program received a call on Aug 7, 2015 that a medical event occurred in the radiation oncology department at Wellstar Kennestone Hospital on August 5, 2015. The event was found out 2 days later when the physicist was reviewing the patient's records on Aug 7, 2015.

"Patient was being treated for cervical cancer (T&O implant) using the HDR (Ir-192, 5 Ci) . The authorized user had prescribed a treatment plan and then changed it to a reduced dose by 1/3 for 3 fractions. The first 2 fractions the patient received the reduced dose. On the third fraction, the 1st plan was delivered. The total dose delivered exceed the prescribed dose by [greater than] 20 percent and the fractionated dose delivered differs from the prescribed dose by more than 50 percent. The authorized user determined no harm came to the patient. The authorized user will be informing the patient on August 7, 2015.

"The dose delivered on the 3rd fraction was 900 cGy and for the T&O implant, the total dose received for all 3 fractions was 1500 cGy."

* * * UPDATE AT 0808 EDT ON 8/11/2015 FROM TRAVIS CARTOSKI TO MARK ABRAMOVITZ * * *

The following information was received via e-mail:

"First fraction delivered was 300 cGy
Second faction delivered was 300 cGy
Third fraction delivered was 900 cGy, should have been 300 cGy
Total dosed received 1500 cGy

"On August 4, 2015, the patient received the first fraction. The physicist confirmed with the AU [Authorized User] that the plan was 900 cGy , 3 fractions and began the treatment. The dwell time for each fraction for the first plan was 1128.4 sec. After realizing how much dose was being delivered to the patient, the AU ordered to stop the treatment 219 sec into the treatment. A new written directive was prepared for 300 cGy per fraction, 900 cGy total. The first fraction continued to be delivered with the second plan. The total volume treated with the first plan was subtracted out from the seconded plan. The first two fractions the patient received the correct amount (300 cGy).

"On August 7, 2015, the patient was scheduled to receive her third fraction. When the patient's chart is pulled up on the computer console, both plans are displayed, the first plan and the second plan. The first plan auto defaults as the current plan being used. The physicist accidently used the initial plan (900 cGy/fraction) for the third fraction. It wasn't until August 7, 2015 when the physicist was reviewing the patients chart when she realized the first plan was delivered on the third fraction. The dwell time for each fraction should have been 350 sec. However, the dwell time for the third fraction was 1128 sec.

"The authorized user determined no harm came to the patient. The authorized user will be informing the patient on August 8, 2015."

Notified the R1DO (Powell) and NMSS Events Resource (via e-mail).

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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Power Reactor Event Number: 51321
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: KEITH HUFF
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/14/2015
Notification Time: 18:09 [ET]
Event Date: 08/03/2015
Event Time: 09:00 [CDT]
Last Update Date: 08/14/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BOB HAGAR (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF SIRENS DUE TO LOSS OF POWER

"On August 14, 2015, the Grand Gulf Nuclear Station (GGNS) determined that less than 75% of the population in the ten mile EPZ could have been notified using the alert notification system (sirens). This condition existed between the time period starting sometime after 1800 [CDT] on Friday, July 31, 2015 until 1630 [CDT] on Monday August 3, 2015.

"The completion of this notification was delayed because at the time of discovery the available information and built in system redundancy supported a conclusion that greater than 75% of the population could have been notified using the siren system. The diversity of the systems required repairs and testing to be coordinated with local officials in both Mississippi and Louisiana.

"At 1000 CDT hours on August 3, 2015, GGNS was informed that the Claiborne County Emergency Operations Center (EOC) siren activation equipment had lost power over the weekend. Investigations and repairs were initiated by Claiborne County Emergency management upon discovery. The system was repaired and functional at 1630 hours on August 3, 2015."

The licensee reported that 30 of 42 sirens lost power.

The NRC Resident Inspector has been notified.

Page Last Reviewed/Updated Monday, August 17, 2015
Monday, August 17, 2015