Event Notification Report for September 20, 2019
U.S. Nuclear Regulatory Commission Event Reports For ** EVENT NUMBERS ** |
| 54269 | 54270 | 54286 |
| Agreement State | Event Number: 54269 |
| Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: PHYSICIANS SURGICAL CENTER OF FORT WORTH LLP Region: 4 City: FORT WORTH State: TX County: License #: L05863 Agreement: Y Docket: NRC Notified By: KAREN BLANCHARD HQ OPS Officer: DONALD NORWOOD | Notification Date: 09/11/2019 Notification Time: 18:23 [ET] Event Date: 09/11/2019 Event Time: 00:00 [CDT] Last Update Date: 09/13/2019 |
| Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE | Person (Organization): RYAN ALEXANDER (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) |
Event Text
| MEDICAL EVENT - PALLADIUM-103 SEEDS IMPLANTED TO WRONG TARGET AREA The following information was received from the Texas Department of State Health Services via E-mail: "On September 11, 2019, the Agency [Texas Department of State Health Services] was notified that the licensee had identified that a medical event had occurred at its facility. The licensee reported it had discovered that the 52 palladium-103 seeds (1.292 mCi each) that had been implanted into a patient on August 1, 2019, which were intended to deliver 100 gray to the prostate, were all inferior to the patient's prostate approximately four centimeters. "The licensee has notified the referring physician and patient. The licensee stated the current plan is to implant the prostate. There are no significant adverse effects expected. "An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300." * * * UPDATE RECEIVED FROM ART TUCKER TO OSSY FONT ON 09/13/19 AT 1752 EDT * * * "On September 13, 2019, the Agency received additional information on this event. The licensee's report stated that on August 1, 2019, the physician was using ultrasound imaging to locate the prostate [and] misidentified the penile bulb as the prostate. The licensee stated this occurred because the penile bulb was very similar in size (10.8 cc versus 12 cc for the prostate) and they were very close to each other. As a result, 52, 1.292 milliCurie (67.2 milliCurie total) Palladium-103 seeds were placed four centimeters inferior to the prostate. The error was not discovered until September 11, 2019 during the post-implant dosimetry review. "The estimated exposure to 90 percent of the penile bulb is 73 gray. The report stated that the patient is elderly and not sexually active; therefore, there is no increased risk of erectile dysfunction. The licensee identified the urethral structure as additional tissue at risk, but expected the effects to be the same as if the seeds had been properly placed at the prostate. The estimated dose to the prostate was 0 gray. Additional information will be provided as it is received in accordance with SA-300." Texas Incident No.: I-9710 Notified R4DO (Alexander) and NMSS Events Notification E-mail group. 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. |
| Agreement State | Event Number: 54270 |
| Rep Org: ARIZONA RADIATION REGULATORY AGENCY Licensee: AMC#102 Region: 4 City: PHOENIX State: AZ County: License #: GENERAL LICENSE Agreement: Y Docket: NRC Notified By: BRIAN GORETZKI HQ OPS Officer: DONALD NORWOOD | Notification Date: 09/11/2019 Notification Time: 19:00 [ET] Event Date: 09/11/2019 Event Time: 00:00 [MST] Last Update Date: 09/11/2019 |
| Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE | Person (Organization): RYAN ALEXANDER (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) CNSNS (MEXICO) (EMAIL) |
| This material event contains a "Less than Cat 3" level of radioactive material. |
Event Text
| LOST / STOLEN TRITIUM EXIT SIGN The following information was received from the Arizona Department of Health Services via E-mail: "The Department [Arizona Department of Health Services] received notification that a tritium exit sign has been lost/stolen. The model is an Isolite 2040 with an activity of approximately 7.5 curies. The Department has requested additional information and continues to investigate the event." Arizona Incident Number: 19-018 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 |
| Power Reactor | Event Number: 54286 |
| Facility: CATAWBA Region: 2 State: SC Unit: [] [2] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: WILL FOWLER HQ OPS Officer: THOMAS KENDZIA | Notification Date: 09/19/2019 Notification Time: 14:08 [ET] Event Date: 07/06/2019 Event Time: 01:56 [EDT] Last Update Date: 09/19/2019 |
| Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD 50.72(b)(3)(v)(B) - POT RHR INOP 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION | Person (Organization): BRIAN BONSER (R2DO) |
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | |||||||
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
Event Text
| BOTH TRAINS OF COMPONENT COOLING WATER DETERMINED INOPERABLE "10 CFR 50.72(b)(3)(v)(A, B, and D) - Event or Condition that Could Have Prevented the Fulfillment of a Safety Function Unit 2 Component Cooling water system inoperable. "On July 6, 2019, from 0156 to 1545 [EDT], it was determined that both trains of the unit 2 component cooling water system were simultaneously inoperable; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). The affected safety function was restored on July 6, 2019, at 1545 [EDT] when the 2B component cooling train was restored to operable. "There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified." At the time of the event no other safety related systems were inoperable. The event had no impact on Unit 1. |
Page Last Reviewed/Updated Wednesday, March 24, 2021
Page Last Reviewed/Updated Wednesday, March 24, 2021