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Event Notification Report for July 14, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/13/2020 - 7/14/2020

** EVENT NUMBERS **


54763 54764 54776

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Agreement State Event Number: 54763
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: Cleveland Clinic Florida - Weston
Region: 1
City: Weston   State: FL
County:
License #: 3871-1
Agreement: Y
Docket:
NRC Notified By: David Pieski
HQ OPS Officer: Brian P. Smith
Notification Date: 07/06/2020
Notification Time: 11:40 [ET]
Event Date: 07/01/2020
Event Time: 00:00 [EDT]
Last Update Date: 07/06/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received via email:

"A 98 microCurie I-125 breast cancer localization seed (titanium encapsulated) was inadvertently cut in half during its extraction from a patient. All portions of seed presumably removed and lavage performed. A pancake probe was used at tissue surface prior to tissue closure and measured 200 microR/hr. Tissue entry point was closed and re-surveyed at some later time with a measurement of 10 microR/hr. Post recovery, patient was apprised of the event and initiated a 10-day KI treatment plan. [The Radiation Safety Regional Health Director] is in consultation with the dose calibrator manufacturer and seed manufacturer (Team Best) in order to better calculate activity of recovered seed portions and subsequently compare to initial, inserted activity. The difference will yield activity remaining in the patient."

Florida Incident Number: FL20-073

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: 54764
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: University of Iowa
Region: 3
City: Iowa City   State: IA
County:
License #: 0037-1-52-AAB
Agreement: Y
Docket:
NRC Notified By: Randal Dahlin
HQ OPS Officer: Jeffrey Whited
Notification Date: 07/06/2020
Notification Time: 13:26 [ET]
Event Date: 07/02/2020
Event Time: 00:00 [CDT]
Last Update Date: 07/06/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
KARLA STOEDTER (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received via email:

"On 6/30/20 microspheres were injected in the patient [intended target of Hepatic Segments 4 through 8] at the vessel branch point with the intention of targeting both the right hepatic artery (RHA) and the middle hepatic artery (MHA). However, post-therapy imaging demonstrates that radiotracer was preferentially deposited along the MHA distribution. This is attributed to unforeseeable clumping of microspheres at the origin of the RHA, such that a majority of the microspheres were preferentially injected into MHA. As such, microspheres were predominantly deposited in the extrahepatic lymph node as well as an unexpected pancreaticoduodenal lymph node. Deposition in this second node can be attributed to additional unintended reflux into a third branching vessel upstream from the RHA and MHA, and further supports the assertion flow into the RHA was hindered by the clumping of microsphere particles. Ultimately, SPECT-CT image analysis suggests no more than approximately 40 percent of the therapy dose was deposited within the liver (as detailed below).

"It is estimated the following activity distribution from post-treatment imaging: At most, approximately 40 percent of the administered activity appears to be within the liver, with the other 60 percent being in extrahepatic tissue (e.g. lymph nodes). This breakdown should be considered approximate, as these images are not scatter corrected.

"From pre-treatment macro aggregated albumin (MAA) imaging, it appears that 84 percent of the administered activity was expected to be delivered to the liver, and 16 percent was expected to shunted to the nodes. Overall, this indicates that approximately 53 percent less activity than what was intended reached the liver. There is uncertainty in this estimate.

"The dose to extrahepatic tissue (lymph nodes) differs from what was intended/expected by more than 50 Rem (0.5 Gy)."

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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Power Reactor Event Number: 54776
Facility: Vogtle
Region: 2     State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: Kelli Roberts
HQ OPS Officer: Dan Livermore
Notification Date: 07/13/2020
Notification Time: 17:10 [ET]
Event Date: 07/13/2020
Event Time: 08:31 [EDT]
Last Update Date: 07/13/2020
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
MARK MILLER (R2DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Under Construction 0 Under Construction
4 N N 0 Under Construction 0 Under Construction

Event Text

SUPERVISOR FAILED FITNESS FOR DUTY TEST

"On July 13, 2020 at 0831 (EDT), Southern Nuclear Operating Company (SNC) determined an SNC supervisory personnel failed their fitness for duty test. The employee has been removed from the site and their access has been terminated. The NRC Resident Inspector has been notified."


Page Last Reviewed/Updated Tuesday, July 14, 2020
Tuesday, July 14, 2020