Event Notification Report for October 16, 2015

AGREEMENT STATE REPORT - PATIENT DOSED WITH WRONG ORGAN UPTAKE TAG

The following information was received from the state of Louisiana via email:

"On October 19, 2015, the Radiology/Nuclear Medicine Manager, reported that on October 16, 2015 at 1200 hours, a PRN Licensed Nuclear Medicine Tech inadvertently dosed a patient with 25 mCi of Tc-99-MDP. The error was detected shortly after administration. The patient had physician's orders to have a cardiac scan utilizing 25 mCi of Tc-99-Tetrofosmin. The isotope activity was correct. However, the organ uptake tag was incorrect.

"The error resulted from the Nuclear Medicine Tech not using the patient two identifiers before administering the unit dose. The activity was correct for the unit dose, but the organ uptake tag was different.

"The facility employees were off and a PRN Tech was filling-in on that Friday. This Tech is used at the facility frequently when an essential employee is absent. He is no stranger to the work environment of the Facility/Licensee.

"The source was a 25 mCi Tc-99 unit dose. He performed the receipt procedures, unit dose assay, and utilized procedures to administer the isotope, but did not cross-reference the name on the unit dose with the individual who received the injection.

"This site is a Medical Institution. The unit doses are kept in a locked 'HOT' lab in the Nuclear Medicine Department. KLS Physics Consultants was called in the help with the reporting requirements.

"The Tech was counselled and retrained in the facility's procedures for patient identification and administration of radioactive materials for human in vivo imaging.

"The patient will receive the correct unit dose and scan, 25 mCi Tc-99-Tetrofosmin, for a cardiac scan at a later date."

Event Report ID No.: LA-150018, T166800

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.

OFFSITE NOTIFICATION MADE FOR HAZARDOUS CHEMICAL SPILL

"At 1115 EDT there was a non-oil chemical spill at the main intake structure during delivery of corrosion inhibitor. The spill occurred due to a failed tank-fill connection. Approximately 10 gallons of the inhibitor reached the Ohio River. The spill has been stopped and contained, and recovery is in progress. This is not a CERCLA (Comprehensive Environmental Response Compensation and Liability Act), Reportable Quantity for the Environmental Protection Agency. However, at 1245 EDT, it was determined to be reportable to the Pennsylvania Department of Environmental Protection (PADEP), in accordance with the Pennsylvania Clean Streams Law and NPDS (National Pollutant Discharge Elimination), permit; thus, a notification was made, to the PADEP, at 1250 hours EDT .

"This condition is being reported pursuant to 10 CFR 50.72 (b)(2)(xi).

"The NRC Resident Inspector has been notified."

PART 21 REPORT - 2 MOTORS WERE NOT PROPERLY PREPARED BEFORE SMALL STEEL SHOT BLASTING

The following information is an excerpt from an Howden North America email:

"It was discovered that two motors being prepared for steel shot blasting prior to application of the coating system may not have been properly sealed allowing a small amount of small steel shot blast to enter into the motor."

The two motors have been repaired and returned to FPL (Florida Power and Light Company), no further action is required.

Customer: Florida Power and Light Company
Location/Site: Turkey Point
Motor Serial Numbers: GG153620115 and GG153620116

For questions and additional information, contact:

J. Todd Gunvalson
Director, Quality
Howden North America
7909 Parklane Road
Columbia, SC 29223
Phone 803-741-2716