Event Notification Report for August 18, 2017
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/17/2017 - 08/18/2017
EVENT NUMBERS
5294152914529155291652917
Non-Agreement State
Event Number: 52941
Rep Org: MICHIGAN DEPARTMENT OF CORRECTIONS
Licensee: MICHIGAN DEPARTMENT OF CORRECTIONS
Region: 3
City: MARQUETTE State: MI
County:
License #: GL
Agreement: N
Docket:
NRC Notified By: GENE WOOD
HQ OPS Officer: DONALD NORWOOD
Licensee: MICHIGAN DEPARTMENT OF CORRECTIONS
Region: 3
City: MARQUETTE State: MI
County:
License #: GL
Agreement: N
Docket:
NRC Notified By: GENE WOOD
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/31/2017
Notification Time: 12:40 [ET]
Event Date: 08/18/2017
Event Time: 14:00 [EDT]
Last Update Date: 08/31/2017
Notification Time: 12:40 [ET]
Event Date: 08/18/2017
Event Time: 14:00 [EDT]
Last Update Date: 08/31/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
STOLEN THEN IMPROPERLY DISPOSED OF TRITIUM EXIT SIGNS
A trustee prisoner was found to have removed 10 tritium 'bulbs' from 10 tritium exit signs at Marquette Branch Prison. The trustee prisoner was using the tritium bulbs as night lights. Eight of the 10 tritium bulbs were recovered. The trustee prisoner admitted to having broken two of the tritium bulbs and then flushed them down a toilet. The activity level of the tritium bulbs is unknown at this time.
The recovered eight tritium bulbs are currently in secure storage. These tritium bulbs will be disposed of by an approved/licensed contractor. The trustee prisoner has been removed from trustee status.
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
A trustee prisoner was found to have removed 10 tritium 'bulbs' from 10 tritium exit signs at Marquette Branch Prison. The trustee prisoner was using the tritium bulbs as night lights. Eight of the 10 tritium bulbs were recovered. The trustee prisoner admitted to having broken two of the tritium bulbs and then flushed them down a toilet. The activity level of the tritium bulbs is unknown at this time.
The recovered eight tritium bulbs are currently in secure storage. These tritium bulbs will be disposed of by an approved/licensed contractor. The trustee prisoner has been removed from trustee status.
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
Agreement State
Event Number: 52914
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Region: 4
City: JACKSON State: MS
County:
License #: MS-MBL-01
Agreement: Y
Docket:
NRC Notified By: JAYSON MOAK
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Region: 4
City: JACKSON State: MS
County:
License #: MS-MBL-01
Agreement: Y
Docket:
NRC Notified By: JAYSON MOAK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/18/2017
Notification Time: 17:43 [ET]
Event Date: 08/18/2017
Event Time: 00:00 [CDT]
Last Update Date: 10/19/2017
Notification Time: 17:43 [ET]
Event Date: 08/18/2017
Event Time: 00:00 [CDT]
Last Update Date: 10/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
PART 21 MATERIALS (EMAI)
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
PART 21 MATERIALS (EMAI)
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following report was received via e-mail:
"The licensee's RSO reported a possible medical event for four separate patients, involving a Nucletron Model microSelectron-HDR 106.990 remote afterloading brachytherapy unit. This was noticed during review by the medical physicist. The licensee notified Elekta for confirmation of the software error. The RSO confirmed on 8/18/2017, that two (2) patients were under dosed by more than 20% and the other two (2) patients were being reviewed by the medical physicist.
"An Elekta Notification was sent out to all MS Radioactive Licensees on 8/17/2017, that possess a Nucletron Model microSelectron-HDR."
Source: 12 Ci, Ir-192, Elekta Model 105.002
Mississippi Report: MS-170002
* * * UPDATE AT 1649 EDT ON 10/19/17 FROM JASON MOAK TO S. SANDIN VIA EMAIL * * *
"Update: 10/18/2017
"Licensee reported four (4) medical events utilizing the tandem and ring applicator model within Elekta's Oncentra Brachy Software version 4.5.2. Licensee written report received, 8/23/2017, for the period between 11/8/2016 and 8/15/2017, stated two of the four patients treated using Nucletron Model microSelectron-HDR 106.990 remote afterloading brachytherapy unit and utilizing the tandem and ring applicator model within Oncentra's Treatment Planning software received a dose less than 20% of the prescribed dose to the treatment site (base of the uterus). All of the treated patients received greater than 50 Rem and 50 percent or more of the dose expected from the administration to unintended tissue (vaginal canal). The written directives called for a prescribed dose of 28 Gy for three patients and 27 Gy for one patient, to be delivered in four (4) separate fractions to the base of the uterus. All four (4) fractions were affected for one patient, three (3) fractions for two patients, and only one (1) fraction for one patient, which received 50 percent or more of the dose expected from the administration.
"Patient / Estimated Dose Delivered to Treatment Site / Percent of Intended Dose from Written Directive / Affected Number of Fractions / Expected Range of Doses to Unintended tissue / Estimated Dose to Unintended Tissue
"Patient A / 18.44 Gy / 65.84 % / 4 / 126 cGy and 175 cGy per treatment fraction / > 28 Gy
"Patient B / 21.78 Gy / 77.7 % / 3 / 126 cGy and 175 cGy per treatment fraction / > 7 Gy per fraction (total > 21 Gy)
"Patient C / 23.39 Gy / 83.55 % / 3 / 126 cGy and 175 cGy per treatment fraction / > 7 Gy per fraction (total > 21 Gy)
"Patient D / 26.84 Gy / 99.41 % / 1 / 126 cGy and 175 cGy per treatment fraction / > 14 Gy for one fraction
"A software error occurs in the Oncentra Treatment Planning Software version 4.5.2, whenever the built-in tandem and ring applicator model is used. The microSelection afterloader step size of a measured source path is 2.5 mm. An override to the default step size of 5 mm (RDStore), from the step size of the measured source path in the planning software occurred. A change in the source position step size, from 2.5 mm to 5 mm was not realized by the licensee for the ring catheter but was implemented for the delivery plan. The dose distribution, prescription point values, and dose volume histogram readouts were all based on a 5 mm spaced tandem and a 2.5 mm spaced ring. When the plans were exported to the treatment unit and delivered, the afterloading brachytherapy unit utilized a source step size of 5 mm for both the tandem and ring applicators, thus a discrepancy between the planned and delivered dose distributions occurred.
"The licensee has suspended use of the tandem and ring applicator model within the software and will define all catheters for the tandem and ring applicator manually until further notice of Elekta's software correction.
"The referring physician and patients have been notified. No adverse health effects were noted for the patients due to the medical events.
"Activity: 12 Ci Licensee Authorization
"Update: (8.85 Ci - 5.195 Ci)
"Date of Incident: 11/8/2016 through 8/15/2017
"List any other actions required of DRH [Mississippi Division of Rad Health]: Licensee notified to send 15-day written report. Elekta Notification, FCA-NU-0004, FCO Reference No. 806-01-BTP-001, was sent out to all MS Radioactive Licensees on 8/17/2017, that possess a Nucletron Model microSelectron-HDR. Licensee's written report received August 23, 2017.
"DRH conducted a reactive inspection of the licensee on September 1, 2017, to determine the cause and further clarify the medical events. The medical events were discussed with the licensee's RSO's, medical physicist(s), and the chair of Radiation Oncology on September 1, 2017, and again on October 17, 2017 and October 18, 2017, with the licensee's medical physicist.
"Case Closed: Yes
"Date Closed: 10/19/2017"
Notified R4DO (Vasquez) 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.
The following report was received via e-mail:
"The licensee's RSO reported a possible medical event for four separate patients, involving a Nucletron Model microSelectron-HDR 106.990 remote afterloading brachytherapy unit. This was noticed during review by the medical physicist. The licensee notified Elekta for confirmation of the software error. The RSO confirmed on 8/18/2017, that two (2) patients were under dosed by more than 20% and the other two (2) patients were being reviewed by the medical physicist.
"An Elekta Notification was sent out to all MS Radioactive Licensees on 8/17/2017, that possess a Nucletron Model microSelectron-HDR."
Source: 12 Ci, Ir-192, Elekta Model 105.002
Mississippi Report: MS-170002
* * * UPDATE AT 1649 EDT ON 10/19/17 FROM JASON MOAK TO S. SANDIN VIA EMAIL * * *
"Update: 10/18/2017
"Licensee reported four (4) medical events utilizing the tandem and ring applicator model within Elekta's Oncentra Brachy Software version 4.5.2. Licensee written report received, 8/23/2017, for the period between 11/8/2016 and 8/15/2017, stated two of the four patients treated using Nucletron Model microSelectron-HDR 106.990 remote afterloading brachytherapy unit and utilizing the tandem and ring applicator model within Oncentra's Treatment Planning software received a dose less than 20% of the prescribed dose to the treatment site (base of the uterus). All of the treated patients received greater than 50 Rem and 50 percent or more of the dose expected from the administration to unintended tissue (vaginal canal). The written directives called for a prescribed dose of 28 Gy for three patients and 27 Gy for one patient, to be delivered in four (4) separate fractions to the base of the uterus. All four (4) fractions were affected for one patient, three (3) fractions for two patients, and only one (1) fraction for one patient, which received 50 percent or more of the dose expected from the administration.
"Patient / Estimated Dose Delivered to Treatment Site / Percent of Intended Dose from Written Directive / Affected Number of Fractions / Expected Range of Doses to Unintended tissue / Estimated Dose to Unintended Tissue
"Patient A / 18.44 Gy / 65.84 % / 4 / 126 cGy and 175 cGy per treatment fraction / > 28 Gy
"Patient B / 21.78 Gy / 77.7 % / 3 / 126 cGy and 175 cGy per treatment fraction / > 7 Gy per fraction (total > 21 Gy)
"Patient C / 23.39 Gy / 83.55 % / 3 / 126 cGy and 175 cGy per treatment fraction / > 7 Gy per fraction (total > 21 Gy)
"Patient D / 26.84 Gy / 99.41 % / 1 / 126 cGy and 175 cGy per treatment fraction / > 14 Gy for one fraction
"A software error occurs in the Oncentra Treatment Planning Software version 4.5.2, whenever the built-in tandem and ring applicator model is used. The microSelection afterloader step size of a measured source path is 2.5 mm. An override to the default step size of 5 mm (RDStore), from the step size of the measured source path in the planning software occurred. A change in the source position step size, from 2.5 mm to 5 mm was not realized by the licensee for the ring catheter but was implemented for the delivery plan. The dose distribution, prescription point values, and dose volume histogram readouts were all based on a 5 mm spaced tandem and a 2.5 mm spaced ring. When the plans were exported to the treatment unit and delivered, the afterloading brachytherapy unit utilized a source step size of 5 mm for both the tandem and ring applicators, thus a discrepancy between the planned and delivered dose distributions occurred.
"The licensee has suspended use of the tandem and ring applicator model within the software and will define all catheters for the tandem and ring applicator manually until further notice of Elekta's software correction.
"The referring physician and patients have been notified. No adverse health effects were noted for the patients due to the medical events.
"Activity: 12 Ci Licensee Authorization
"Update: (8.85 Ci - 5.195 Ci)
"Date of Incident: 11/8/2016 through 8/15/2017
"List any other actions required of DRH [Mississippi Division of Rad Health]: Licensee notified to send 15-day written report. Elekta Notification, FCA-NU-0004, FCO Reference No. 806-01-BTP-001, was sent out to all MS Radioactive Licensees on 8/17/2017, that possess a Nucletron Model microSelectron-HDR. Licensee's written report received August 23, 2017.
"DRH conducted a reactive inspection of the licensee on September 1, 2017, to determine the cause and further clarify the medical events. The medical events were discussed with the licensee's RSO's, medical physicist(s), and the chair of Radiation Oncology on September 1, 2017, and again on October 17, 2017 and October 18, 2017, with the licensee's medical physicist.
"Case Closed: Yes
"Date Closed: 10/19/2017"
Notified R4DO (Vasquez) 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.
Power Reactor
Event Number: 52915
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: DAN JAMES
HQ OPS Officer: BETHANY CECERE
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: DAN JAMES
HQ OPS Officer: BETHANY CECERE
Notification Date: 08/18/2017
Notification Time: 23:41 [ET]
Event Date: 08/18/2017
Event Time: 20:55 [CDT]
Last Update Date: 08/18/2017
Notification Time: 23:41 [ET]
Event Date: 08/18/2017
Event Time: 20:55 [CDT]
Last Update Date: 08/18/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
THOMAS FARNHOLTZ (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 100 | Power Operation | 0 | Hot Shutdown |
AUTOMATIC SCRAM WHILE AT 100 PERCENT POWER
"At 2055 CDT on August 18, 2017, an automatic actuation of the reactor protection system occurred while the plant was operating at 100 percent power. No plant parameters requiring the actuation of the emergency diesel generators or the emergency core cooling system were exceeded. The main feedwater system remained in service following the scram to maintain reactor water level, and the main condenser remained available as the normal heat sink.
"The scram occurred after a planned swap of the main feedwater master controller channels in preparation for scheduled surveillance testing. When the channel swap was actuated, the feedwater regulating valves moved to the fully open position. The scram signal originated in the high-flux detection function of the average power range monitors, apparently from the rapid increase in feedwater flow.
"The cause of the apparent feedwater controller malfunction is under investigation. The NRC Resident Inspector has been notified."
No safety relief valves opened. Decay heat is being removed via steam to the main condenser using the bypass valves and steam drains. The licensee intends to go to Cold Shutdown to investigate the malfunction.
"At 2055 CDT on August 18, 2017, an automatic actuation of the reactor protection system occurred while the plant was operating at 100 percent power. No plant parameters requiring the actuation of the emergency diesel generators or the emergency core cooling system were exceeded. The main feedwater system remained in service following the scram to maintain reactor water level, and the main condenser remained available as the normal heat sink.
"The scram occurred after a planned swap of the main feedwater master controller channels in preparation for scheduled surveillance testing. When the channel swap was actuated, the feedwater regulating valves moved to the fully open position. The scram signal originated in the high-flux detection function of the average power range monitors, apparently from the rapid increase in feedwater flow.
"The cause of the apparent feedwater controller malfunction is under investigation. The NRC Resident Inspector has been notified."
No safety relief valves opened. Decay heat is being removed via steam to the main condenser using the bypass valves and steam drains. The licensee intends to go to Cold Shutdown to investigate the malfunction.
Agreement State
Event Number: 52916
Rep Org: NIST
Licensee: NIST
Region: 1
City: GAITHERSBURG State: MD
County:
License #: SNM-362
Agreement: Y
Docket:
NRC Notified By: MANUEL MEJIAS
HQ OPS Officer: STEVEN VITTO
Licensee: NIST
Region: 1
City: GAITHERSBURG State: MD
County:
License #: SNM-362
Agreement: Y
Docket:
NRC Notified By: MANUEL MEJIAS
HQ OPS Officer: STEVEN VITTO
Notification Date: 08/19/2017
Notification Time: 12:07 [ET]
Event Date: 08/18/2017
Event Time: 14:00 [EDT]
Last Update Date: 09/08/2017
Notification Time: 12:07 [ET]
Event Date: 08/18/2017
Event Time: 14:00 [EDT]
Last Update Date: 09/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(1) - UNPLANNED CONTAMINATION
10 CFR Section:
30.50(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
TYRONE NAQUIN (PM)
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
TYRONE NAQUIN (PM)
UNPLANNED CONTAMINATION EVENT - BROKEN FLAME-SEALED GLASS AMPOULE
"The purpose of this communication is to provide additional details surrounding the circumstances that led to the identification of unplanned contamination in one of the laboratories designated as a restricted area under the US NRC license SNM-362. As indicated verbally during the initial report at 1207 EDT, and required by 10 CFR 30.50(b)(1), this event is described as having a broken flame-sealed glass ampoule that resulted in contamination of the lead-shielding storage area on top of the countertop and other surfaces within room C11 in building 245 of the NIST Gaithersburg, MD campus. This was discovered at approximately 1400 EDT on 8/18/2017.
"The ampoule contained a well-characterized solution of Am-241 with an activity of approximately 47 MBq (most restrictive ALI [Annual Limit on Intake] is 0.006 uCi) and is registered in our database as being in a solution of nitric acid.
"The initial report requirements of 10 CFR 30.50(b)(1)(i) through (iii) are satisfied by the phone notification and supplemented by this communication and attachments. Additional information regarding corrective actions taken and planned, as well as evaluations and/or assessments, will be provided to our Project Manager and Region I in the near future and the required written report will be provided within the required 30 days.
"After reporting event #52916, at the direction of the Radiation Safety Officer and with the support of the NIST Senior Management, multiple efforts will continue to evaluate the extent of the condition and a Stop Work Order will be issued effective today for all other laboratories at NIST Gaithersburg that store similar ampoules until the extent of condition is evaluated and/or mitigated.
"Extensive surveys of the area and air monitoring have confirmed that the contamination is isolated to portions of room C11."
Access has been restricted to room C11.
The licensee notified NRC R1 (Ullrich) and NRC HQ PM (Naquin) regarding this event.
* * * UPDATE FROM MANUEL MEJIAS TO HOWIE CROUCH AT 1209 EDT ON 9/6/17 * * *
The licensee received three bioassay results from personnel exposure to the contaminant. Two of the bioassays were negative. The third bioassay indicated the exposed individual received 9.1 REM whole body with 87 REM to the bone surface of the target organ. Additional bioassays are being performed.
The licensee notified R1 (Ullrich and Jackson) and HQ (Naquin).
Notified R1DO (Dentel), NMSS (Rivera-Capella), and NMSS Events Notification (email).
* * * UPDATE AT 1838 EDT ON 09/08/17 FROM MANUEL MEJIAS TO S. SANDIN * * *
"The purpose of this communication is to provide additional details regarding Event # 52916 as results of radiological surveys, interviews, and bioassays are obtained. As indicated verbally during the NRC Ops Center phone update today at 18:38 EDT, new survey and interviews information have led us to believe that ingestion was a possible pathway for the individual that had a positive bioassay. Given the difference in the intake retention fraction (IRF) for ingestion versus inhalation pathway, we have performed additional calculations of the previous bioassay results. These calculations have identified the potential for a total effective dose equivalent of 25 rem or more.
"Given the potential for dose of 25 rem or more, consultation was done with the REAC/TS team. Additional bioassays and medical evaluation will be performed.
"A courtesy notification was provided earlier today to R1 (Ullrich) and HQ (Naquin)."
Notified R1DO (Dentel), NMSS (Collins) and INES Coordinator (Rivera-Capella), INES National Officer (Milligan) via email.
"The purpose of this communication is to provide additional details surrounding the circumstances that led to the identification of unplanned contamination in one of the laboratories designated as a restricted area under the US NRC license SNM-362. As indicated verbally during the initial report at 1207 EDT, and required by 10 CFR 30.50(b)(1), this event is described as having a broken flame-sealed glass ampoule that resulted in contamination of the lead-shielding storage area on top of the countertop and other surfaces within room C11 in building 245 of the NIST Gaithersburg, MD campus. This was discovered at approximately 1400 EDT on 8/18/2017.
"The ampoule contained a well-characterized solution of Am-241 with an activity of approximately 47 MBq (most restrictive ALI [Annual Limit on Intake] is 0.006 uCi) and is registered in our database as being in a solution of nitric acid.
"The initial report requirements of 10 CFR 30.50(b)(1)(i) through (iii) are satisfied by the phone notification and supplemented by this communication and attachments. Additional information regarding corrective actions taken and planned, as well as evaluations and/or assessments, will be provided to our Project Manager and Region I in the near future and the required written report will be provided within the required 30 days.
"After reporting event #52916, at the direction of the Radiation Safety Officer and with the support of the NIST Senior Management, multiple efforts will continue to evaluate the extent of the condition and a Stop Work Order will be issued effective today for all other laboratories at NIST Gaithersburg that store similar ampoules until the extent of condition is evaluated and/or mitigated.
"Extensive surveys of the area and air monitoring have confirmed that the contamination is isolated to portions of room C11."
Access has been restricted to room C11.
The licensee notified NRC R1 (Ullrich) and NRC HQ PM (Naquin) regarding this event.
* * * UPDATE FROM MANUEL MEJIAS TO HOWIE CROUCH AT 1209 EDT ON 9/6/17 * * *
The licensee received three bioassay results from personnel exposure to the contaminant. Two of the bioassays were negative. The third bioassay indicated the exposed individual received 9.1 REM whole body with 87 REM to the bone surface of the target organ. Additional bioassays are being performed.
The licensee notified R1 (Ullrich and Jackson) and HQ (Naquin).
Notified R1DO (Dentel), NMSS (Rivera-Capella), and NMSS Events Notification (email).
* * * UPDATE AT 1838 EDT ON 09/08/17 FROM MANUEL MEJIAS TO S. SANDIN * * *
"The purpose of this communication is to provide additional details regarding Event # 52916 as results of radiological surveys, interviews, and bioassays are obtained. As indicated verbally during the NRC Ops Center phone update today at 18:38 EDT, new survey and interviews information have led us to believe that ingestion was a possible pathway for the individual that had a positive bioassay. Given the difference in the intake retention fraction (IRF) for ingestion versus inhalation pathway, we have performed additional calculations of the previous bioassay results. These calculations have identified the potential for a total effective dose equivalent of 25 rem or more.
"Given the potential for dose of 25 rem or more, consultation was done with the REAC/TS team. Additional bioassays and medical evaluation will be performed.
"A courtesy notification was provided earlier today to R1 (Ullrich) and HQ (Naquin)."
Notified R1DO (Dentel), NMSS (Collins) and INES Coordinator (Rivera-Capella), INES National Officer (Milligan) via email.
Non-Agreement State
Event Number: 52917
Rep Org: WASHINGTON UNIVERSITY
Licensee: WASHINGTON UNIVERSITY
Region: 3
City: St. Louis State: MO
County:
License #: 24-00167-11
Agreement: N
Docket:
NRC Notified By: SUSAN LANGHORST
HQ OPS Officer: DONALD NORWOOD
Licensee: WASHINGTON UNIVERSITY
Region: 3
City: St. Louis State: MO
County:
License #: 24-00167-11
Agreement: N
Docket:
NRC Notified By: SUSAN LANGHORST
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/19/2017
Notification Time: 16:14 [ET]
Event Date: 08/18/2017
Event Time: 14:00 [CDT]
Last Update Date: 08/19/2017
Notification Time: 16:14 [ET]
Event Date: 08/18/2017
Event Time: 14:00 [CDT]
Last Update Date: 08/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
AARON McCRAW (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AARON McCRAW (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
MEDICAL EVENT - Y-90 THERASPHERES ADMINISTERED TO THE WRONG LIVER LOBE
"A medical event occurred on 8/18/2017 when Y-90 TheraSpheres meant for treatment of the patient's left liver lobe were administered to the patient's right liver lobe. The patient treatment plan was for radioembolization of the left lobe of the liver on 8/18/17 and radioembolization of the right liver lobe approximately one month later. The interventional radiologist (IR) and radiation oncologist authorized user (AU) signed off on planning activity for the left lobe via the left hepatic artery on 8/2/17 and 8/3/17, respectively. The AU completed the 8/18/17 written directive to deliver 124 Gy to the left lobe via the left hepatic artery (LHA). The IR placed the catheter for treatment in the right hepatic artery which supplies the right liver lobe. The AU, medical physicist and radiation technologist came to the procedure room. A time out procedure was done asking all parties to confirm 124 Gy to the left lobe via the LHA. The IR gave a verbal affirmation of this plan. The IR discovered the error when reviewing patient notes following the procedure. He immediately notified the AU who then notified the Radiation Safety Officer (RSO). The AU estimated dose to the right lobe to be 63 Gy. The RSO continues investigating the event. The patient and the referring physician were notified of the medical event."
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.
"A medical event occurred on 8/18/2017 when Y-90 TheraSpheres meant for treatment of the patient's left liver lobe were administered to the patient's right liver lobe. The patient treatment plan was for radioembolization of the left lobe of the liver on 8/18/17 and radioembolization of the right liver lobe approximately one month later. The interventional radiologist (IR) and radiation oncologist authorized user (AU) signed off on planning activity for the left lobe via the left hepatic artery on 8/2/17 and 8/3/17, respectively. The AU completed the 8/18/17 written directive to deliver 124 Gy to the left lobe via the left hepatic artery (LHA). The IR placed the catheter for treatment in the right hepatic artery which supplies the right liver lobe. The AU, medical physicist and radiation technologist came to the procedure room. A time out procedure was done asking all parties to confirm 124 Gy to the left lobe via the LHA. The IR gave a verbal affirmation of this plan. The IR discovered the error when reviewing patient notes following the procedure. He immediately notified the AU who then notified the Radiation Safety Officer (RSO). The AU estimated dose to the right lobe to be 63 Gy. The RSO continues investigating the event. The patient and the referring physician were notified of the medical event."
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.