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Event Notification Report for January 13, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/12/2017 - 01/13/2017

** EVENT NUMBERS **


52376 52473 52475 52486

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 52376
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: MOUNT AUBURN HOSPITAL
Region: 1
City: CAMBRIDGE State: MA
County:
License #: 44-0017
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/18/2016
Notification Time: 12:22 [ET]
Event Date: 11/16/2016
Event Time: 09:00 [EST]
Last Update Date: 01/12/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFICA (E-MA)

Event Text

AGREEMENT STATE REPORT - MEDICAL RADIATION TREATMENT OVERDOSE

The following information was received via E-mail:

"The licensee reported on November 17, 2016 that the licensee administered on November 16, 2016 to a patient a first fraction dose of 1100 centigray to the vagina instead of the prescribed first fraction dose of 600 centigray to the vagina.

"This dose was the first of three fractionated doses, the second and third fractionated doses have not yet been administered. Each fractionated dose was prescribed to be 600 centigray for a total dose of 18 gray (1,800 centigray).

"The licensee used a Varian Medical Systems, Inc. GammaMed plus iX High Dose Rate (HDR) remote afterloader unit containing 7 curies of iridium-192 to deliver the dose.

"This is a reportable medical event in accordance with 105 CMR 120.594(A)(1)(a)3.

"The licensee reported that the patient and the referring physician have been notified and that no harmful effect to the patient has been reported.

"The licensee reported that the event occurred because the physician's plan was not performed as prescribed in the written directive and that no other cause was known at time of report.

"The Agency (Massachusetts Radiation Control Program) Director requested the licensee to cease HDR use until a corrective action to prevent recurrence has been implemented.

"The Agency plans to perform a special inspection and considers this event to be open."

* * * RETRACTION FROM JOSHUA DAEHLER TO JOHN SHOEMAKER AT 1506 EST ON 01/12/17 * * *

"The Agency is retracting this medical event. This is not a reportable event.

"Based upon inspection/review by the Agency with the licensee, it was determined that each of the three fractions was actually prescribed to be 700 centigray for a total dose of 2,100 centigray to the vagina. The first fraction dose of 700 centigray was successfully administered to the vagina. The two additional fraction doses of 700 centigray each were also successfully administered to the vagina. The licensee prematurely reported the issue without having all the facts and without review by the RSO. Subsequently to review of information available to the licensee it was determined no reportable event occurred."

Notified R1DO (Dimitriadis) 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: 52473
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT PROVIDED
Region: 1
City: NOT PROVIDED State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: NOT PROVIDED
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/04/2017
Notification Time: 16:03 [ET]
Event Date: 12/29/2016
Event Time: [EST]
Last Update Date: 01/04/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following report was received via fax:

"We [New York State Department of Health] were informed on January 3, 2017 that on December 29, 2016, a 61 year old female patient was to receive SIR spheres Y90 infusion to 2 lesions in her liver at a hospital. The small lesion was to receive 10% and the large lesion was to receive 90% of 24.53 mCi Y90.

"Staff prepared 2 vials according to the Written Directive, and labeled each vial shield. When the first infusion, for the smaller lesion, was called for, a technologist took one vial to the IR room. She believed she had the correct 10% marked vial. She removed the top of the shielded container holding the vial, then she left the IR suite. The patient was injected. When the second infusion, for the large lesion, was called for, the same technologist took the second shielded vial from the hot lab and noticed that it was the one marked with the 10% label. It appears that the vials themselves were not labeled, only the lids of the containers holding the vials were labeled. Once they realized what had happened, they decided to infuse the second larger lesion with what was left over in the first vial as well as what was in the second vial. The licensee has not yet provided the values for the actual administered dose to each lesion. However, it appears clear that the discrepancy in the prescribed activity and administered activity for each lesion meets the reportable medical event criteria.

"[The licensee's] initial report stated there is no harm to the patient. A full report, including the actual activity delivered and a root cause analysis is required/pending."

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: 52475
Rep Org: COLORADO DEPT OF HEALTH
Licensee: CHATEAU RESIDENCE CLUB
Region: 4
City: BEAVER CREEK State: CO
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: LINDA BARTISH
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/05/2017
Notification Time: 09:26 [ET]
Event Date: 01/04/2017
Event Time: 11:30 [MST]
Last Update Date: 01/05/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following information was received via e-mail:

"Detail: Chateau Residence Club had a fire inspection that required the removal of two expired tritium exit signs. Encore Electric was contracted to remove the signs approximately around 10-13-16. According to Encore, the staff person performing the work tossed the exit signs in the trash. Encore Electric was informed by CDPHE [Colorado, Department of Public Health and Environment]/General License Coordinator to complete a corrective action to include tracking to disposal of all tritium exit signs, writing a report explaining their safety, handling and disposal of radioactive tritium signs. Colorado Rules and Regulations Pertaining to Radiation Control were provided to Encore Electric as guidance to complete the corrective action.

"Manufacturer: Best Lighting Products aka Forever Light.,
Model Number: SLXYU1BB10,
Serial Numbers: 215656 & 215657,
Isotope: H-3,
Activity: 7.09 Ci

"Event Description: Due to the continuous lack of information from manufacturing companies reaching the responsible parties at the destination where exit signs are to be installed; companies have no understanding of the regulations for products containing tritium. The General License Coordinator at CDPHE provided the Chateau Residence Club management a copy of the Colorado Rules and Regulations Pertaining to Radiation Control and the NRC guidelines K & L. The Chateau Residence Club uses sub contractors for services like fire safety and lighting. Encore Electric was unaware of the regulations for Tritium Exit Signs."

Event Report ID No.: CO17-0001

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

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

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Power Reactor Event Number: 52486
Facility: OCONEE
Region: 2 State: SC
Unit: [1] [2] [3]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: DAVID HAILE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/12/2017
Notification Time: 18:25 [ET]
Event Date: 01/12/2017
Event Time: 14:00 [EST]
Last Update Date: 01/12/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
SCOTT SHAEFFER (R2DO)
FFD GROUP (EMAI)

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 Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS-FOR-DUTY TEST POSITIVE FOR NON-LICENSED SUPERVISOR

"A non-licensed supervisor has been found in violation of the Duke Energy Fitness for Duty Policy during a random fitness for duty test. The individual's access to the plant has been suspended.

"The licensee has notified the NRC Senior Resident Inspector."

Page Last Reviewed/Updated Friday, January 13, 2017
Friday, January 13, 2017