Event Notification Report for April 09, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/08/2021 - 04/09/2021
Agreement State
Event Number: 55192
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: University of Washington
Region: 4
City: Seattle State: WA
County:
License #: C001
Agreement: Y
Docket:
NRC Notified By: Tristan Hay
HQ OPS Officer: Joanna Bridge
Licensee: University of Washington
Region: 4
City: Seattle State: WA
County:
License #: C001
Agreement: Y
Docket:
NRC Notified By: Tristan Hay
HQ OPS Officer: Joanna Bridge
Notification Date: 04/14/2021
Notification Time: 13:15 [ET]
Event Date: 04/09/2021
Event Time: 00:00 [PDT]
Last Update Date: 04/28/2021
Notification Time: 13:15 [ET]
Event Date: 04/09/2021
Event Time: 00:00 [PDT]
Last Update Date: 04/28/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PICK, GREG (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
PICK, GREG (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 5/28/2021
EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was received from the Washington State Department of Health:
"University of Washington broad scope license C001 reported a medical event. The event involves Y-90 microspheres contained in two vials of different activity. Vial A and Vial B were to be delivered to different treatment sites. However, the vials were mixed up and the lower activity vial was delivered to the wrong site, the Authorized User (AU) realized it was the wrong vial and did not inject the second vial. This resulted in an underdose of more than 20 percent. A full report is expected in 15 days and will be forwarded."
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.
* * * UPDATE ON 04/28/2021 AT 1321 EDT FROM TRISTAN DAY TO BRIAN P. SMITH * * *
The following update is from the report received via e-mail from the Washington State Department of Health:
"On Friday April 9, 2021, a patient had been prescribed two dosages of yttrium-90 microspheres intended for two different liver treatment sites. One treatment dosage was a larger amount than the other, 35.9 mCi and 21.4 mCi. Both dosages were measured in the Nuclear Medicine CRC 15R dose calibrator prior to use. They were found to be the correctly prescribed amounts and the vials were labelled correctly. Both dosages were transported to the Interventional Radiology suite. When the authorized user (AU) called for the first dosage, the higher of the two activities (35.9 mCi), it was set up and administered, including the required radiation dose rate measurement taken prior to and during the dosing. When the AU called for the second dosage (21.4 mCi), he noticed that the radiation dose rate measurement of the second dosage was higher than it had read for the first administration, which was supposed to be the larger of the two dosages. Realizing that the smaller of the two dosages was mistakenly administered first, the physician stopped the treatment and did not administer the second dosage. It was then confirmed that the patient received the lower of the two dosages (21.4 mCi) to the treatment site that was supposed to receive the higher dosage (35.9 mCi). Nuclear Medicine informed the Environmental Health and Safety Department's (EHS) Medical Health Physicist (MHP), and the MHP subsequently informed the Radiation Safety Officer (RSO).
"Initially, there were questions regarding the need to evaluate this event as a possible Medical Event. There was uncertainty regarding applying the medical event criteria to both sites together or to each individual site. Additionally, the first treatment site was under-dosed and the AU subsequently had determined that the dose delivered was adequate for that site.
"After discussing the event with the MHP on Monday morning, April 12, 2021, the RSO requested a meeting with Department of Health (DOH) to discuss the event. The MHP and RSO discussed the event with DOH that afternoon, and DOH informed that it would depend if the written directive included both sites, or if there was a written directive for each site.
"On Tuesday, April 13, 2021, all the required information was obtained, and the MHP and RSO reviewed the dosage and dose calculations and determined that the medical event criteria was met. The dose delivered is less than prescribed, and will result in no harm to the patient and it is the intention of the physician to treat the second site at some future time."
Washington Event Report Number: WA-21-006
Notified R4DO (Proulx) and NMSS Events Notification via email.
EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was received from the Washington State Department of Health:
"University of Washington broad scope license C001 reported a medical event. The event involves Y-90 microspheres contained in two vials of different activity. Vial A and Vial B were to be delivered to different treatment sites. However, the vials were mixed up and the lower activity vial was delivered to the wrong site, the Authorized User (AU) realized it was the wrong vial and did not inject the second vial. This resulted in an underdose of more than 20 percent. A full report is expected in 15 days and will be forwarded."
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.
* * * UPDATE ON 04/28/2021 AT 1321 EDT FROM TRISTAN DAY TO BRIAN P. SMITH * * *
The following update is from the report received via e-mail from the Washington State Department of Health:
"On Friday April 9, 2021, a patient had been prescribed two dosages of yttrium-90 microspheres intended for two different liver treatment sites. One treatment dosage was a larger amount than the other, 35.9 mCi and 21.4 mCi. Both dosages were measured in the Nuclear Medicine CRC 15R dose calibrator prior to use. They were found to be the correctly prescribed amounts and the vials were labelled correctly. Both dosages were transported to the Interventional Radiology suite. When the authorized user (AU) called for the first dosage, the higher of the two activities (35.9 mCi), it was set up and administered, including the required radiation dose rate measurement taken prior to and during the dosing. When the AU called for the second dosage (21.4 mCi), he noticed that the radiation dose rate measurement of the second dosage was higher than it had read for the first administration, which was supposed to be the larger of the two dosages. Realizing that the smaller of the two dosages was mistakenly administered first, the physician stopped the treatment and did not administer the second dosage. It was then confirmed that the patient received the lower of the two dosages (21.4 mCi) to the treatment site that was supposed to receive the higher dosage (35.9 mCi). Nuclear Medicine informed the Environmental Health and Safety Department's (EHS) Medical Health Physicist (MHP), and the MHP subsequently informed the Radiation Safety Officer (RSO).
"Initially, there were questions regarding the need to evaluate this event as a possible Medical Event. There was uncertainty regarding applying the medical event criteria to both sites together or to each individual site. Additionally, the first treatment site was under-dosed and the AU subsequently had determined that the dose delivered was adequate for that site.
"After discussing the event with the MHP on Monday morning, April 12, 2021, the RSO requested a meeting with Department of Health (DOH) to discuss the event. The MHP and RSO discussed the event with DOH that afternoon, and DOH informed that it would depend if the written directive included both sites, or if there was a written directive for each site.
"On Tuesday, April 13, 2021, all the required information was obtained, and the MHP and RSO reviewed the dosage and dose calculations and determined that the medical event criteria was met. The dose delivered is less than prescribed, and will result in no harm to the patient and it is the intention of the physician to treat the second site at some future time."
Washington Event Report Number: WA-21-006
Notified R4DO (Proulx) and NMSS Events Notification via email.
Power Reactor
Event Number: 55185
Facility: Vogtle
Region: 2 State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: Steven Leighty
HQ OPS Officer: Ossy Font
Region: 2 State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: Steven Leighty
HQ OPS Officer: Ossy Font
Notification Date: 04/09/2021
Notification Time: 16:08 [ET]
Event Date: 04/09/2021
Event Time: 14:05 [EDT]
Last Update Date: 04/09/2021
Notification Time: 16:08 [ET]
Event Date: 04/09/2021
Event Time: 14:05 [EDT]
Last Update Date: 04/09/2021
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
MILLER, MARK (R2)
FFD GROUP, (EMAIL)
MILLER, MARK (R2)
FFD GROUP, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | N | 0 | Power Operation | 0 | Power Operation |
| 4 | N | N | 0 | Power Operation | 0 | Power Operation |
EN Revision Imported Date: 5/7/2021
EN Revision Text: FITNESS FOR DUTY REPORT
A contract employee supervisor had a confirmed positive for illegal drugs during a random fitness-for-duty test. The employee's access to the plant had been terminated.
EN Revision Text: FITNESS FOR DUTY REPORT
A contract employee supervisor had a confirmed positive for illegal drugs during a random fitness-for-duty test. The employee's access to the plant had been terminated.