Event Notification Report for March 30, 2018

AGREEMENT STATE REPORT OF OVEREXPOSURE TO CARDIOLOGIST

The following report was received from the Mississippi Division of Radiological Health via email:

"It was reported, via phone, that an overexposure was received by a Cardiologist in the Ocean Springs Hospital's Catheterization Laboratory. The Cardiologist has received a dose of 5.1 R. The individual reported to the Division of Radiological Health (DRH) of Mississippi that corrective actions were being taken: an investigation was being implemented, dose report(s) were being gathered, and the Cardiologist was being trained on proper handling of ionizing radiation.

"DRH immediately responded by requesting the following information: a report detailing the overexposure, dosimetry reports for the current year, a report on the Radiation Safety Committee's investigation, corrective actions that were taken, and if the overexposure was due to radioactive material or an x-ray device.

"Licensee notified to send a written report of the initial findings by April 5, 2018."

Event Report ID: MS-180004

PRIMARY CONTAINMENT DECLARED INOPERABLE DUE TO BOTH AIRLOCK DOORS OPEN SIMULTANEOUSLY

"On March 30, 2018 at 1305 CDT, with the reactor at 98 percent core thermal power and steady state conditions, plant personnel identified that both doors of the containment personnel airlock were open simultaneously due to failure of the interlock. Personnel were at both the outside and inside doors. Immediate action was taken to close the inner containment personnel airlock door and it was verified closed. Both doors of the containment personnel airlock were open for less than one minute. There was no radioactive release as a result of the event. The cause of the interlock failure is under investigation.

"This condition requires an 8-hour non-emergency notification in accordance with 10 CFR 50.72(b)(3)(ii)(A), the condition of the nuclear power plant, including its principal safety barriers (primary containment), being seriously degraded. This condition is also reportable under 10 CFR 50.72(b)(3)(v)(C) as an event or condition that could have prevented fulfillment of a safety function needed to control the release of radioactive material."

The NRC Resident Inspector was notified.

MISADMINISTRATION OF SIR-SPHERES Y-90 MICROSPHERES RESULTING IN AN UNDERDOSE

The following was received from the State of Washington via email:

"Patient was under treated with Y-90 SIR-Spheres Microspheres. Prescribed dose was 24.59 mCi. Patient was treated with 8.9 mCi.

"Background: SIR-Spheres Microspheres Activity Calculator determined a treatment dose of 0.91 GBq (24.59 mCi). Written Directive was signed for 0.91 GBq. Prescribed dose was entered into the Treatment Worksheet as 0.91 mCi. Dose activity delivered to the interventional radiology procedure room (Dose In-Vial) was recorded as 0.96 mCi.

"Analysis: Radioactivity units of measurement varied between Written Directive and Treatment Worksheet. Radioactivity activity readings from the dose calibrator were recorded with a systematic error. Calibrator reading multiplication factor(x10) was not applied. Therefore, the vial pre-dispense Y-90 activity reading of 8.62 mCi should have been recorded as 86.2 mCi. Dose activity delivered to the IR procedure room was in fact 9.60 mCi rather than 0.96 mCi.

"Y-90 SIR-Spheres treatment on 3/30/2018 was incomplete because the prescribed 0.91 GBq prescribed dose was not administered. Standard post-procedure verification check identified the under treatment. The patient was informed by the prescribing physician and scheduled for a second treatment on 4/6/2018. The second Y-90 SIR-Spheres treatment was performed on 4/6/2018 and the remaining dose was administered to complete administration of the prescribed 0.91 GBq."

Washington State Incident Number: WA-18-010.

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.