Event Notification Report for May 10, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/09/2021 - 05/10/2021
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital
Event Number: 55245
Rep Org: VA National Health Physics Program
Licensee: VA Pittsburgh Healthcare System
Region: 3
City: Little Rock State: AR
County:
License #: 03-23853-01VA
Agreement: N
Docket:
NRC Notified By: Stan Bravenec
HQ OPS Officer: Bethany Cecere
Licensee: VA Pittsburgh Healthcare System
Region: 3
City: Little Rock State: AR
County:
License #: 03-23853-01VA
Agreement: N
Docket:
NRC Notified By: Stan Bravenec
HQ OPS Officer: Bethany Cecere
Notification Date: 05/10/2021
Notification Time: 15:28 [ET]
Event Date: 05/10/2021
Event Time: 07:30 [EST]
Last Update Date: 05/20/2021
Notification Time: 15:28 [ET]
Event Date: 05/10/2021
Event Time: 07:30 [EST]
Last Update Date: 05/20/2021
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
McCRAW, AARON (R3DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
McCRAW, AARON (R3DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 6/17/2021
EN Revision Text: MEDICAL EVENT - PATIENT UNDERDOSE
The following report was received via email from the VA National Health Physics Program (NHPP):
"VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, which holds Permit Number 37-01230-03 under the VA master materials license, reported discovery of a medical event to NHPP at approximately 0730 EDT, May 10, 2021.
"An iodine-131 sodium iodide thyroid ablation therapy administration was performed on Friday, May 7, 2021. The prescribed dose was 60 milliCuries but only 31.2 milliCuries were delivered.
"The patient and the referring physician have been notified.
"NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045.
"NHPP notified [their] NRC Region III Project Manager, Bryan Parker."
* * * RETRACTION ON 5/20/21 AT 1835 EST FROM EDWIN M. LEIDHOLDT, JR. TO BETHANY CECERE * * *
The following retraction was received via email from the VA National Health Physics Program (NHPP):
"A patient at VA Pittsburgh Healthcare System was administered a therapeutic dosage of iodine-131 sodium iodide on May 7, 2021. On May 10, 2021, the facility reported to NHPP that a medical event had occurred. We reported that to NRC Operations Center on May 10, 2021, pursuant to 10 CFR 35.3045. The basis for the medical event was that the facility believed that only a little more than half of the prescribed dosage of 60 milliCuries had been administered to the patient.
"Since that time, measurements were made of the material not administered to the patient. These measurements indicate that about 82% of the prescribed activity was administered and therefore a medical event did not occur. Therefore, we wish to retract the report of the medical event.
"We have notified Bryan Parker of NRC Region III, NRC project manager for the VA's Master Material License, of our plan to withdraw the event declaration."
Notified R3DO (Cameron) and NMSS Events (by 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.
EN Revision Text: MEDICAL EVENT - PATIENT UNDERDOSE
The following report was received via email from the VA National Health Physics Program (NHPP):
"VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, which holds Permit Number 37-01230-03 under the VA master materials license, reported discovery of a medical event to NHPP at approximately 0730 EDT, May 10, 2021.
"An iodine-131 sodium iodide thyroid ablation therapy administration was performed on Friday, May 7, 2021. The prescribed dose was 60 milliCuries but only 31.2 milliCuries were delivered.
"The patient and the referring physician have been notified.
"NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045.
"NHPP notified [their] NRC Region III Project Manager, Bryan Parker."
* * * RETRACTION ON 5/20/21 AT 1835 EST FROM EDWIN M. LEIDHOLDT, JR. TO BETHANY CECERE * * *
The following retraction was received via email from the VA National Health Physics Program (NHPP):
"A patient at VA Pittsburgh Healthcare System was administered a therapeutic dosage of iodine-131 sodium iodide on May 7, 2021. On May 10, 2021, the facility reported to NHPP that a medical event had occurred. We reported that to NRC Operations Center on May 10, 2021, pursuant to 10 CFR 35.3045. The basis for the medical event was that the facility believed that only a little more than half of the prescribed dosage of 60 milliCuries had been administered to the patient.
"Since that time, measurements were made of the material not administered to the patient. These measurements indicate that about 82% of the prescribed activity was administered and therefore a medical event did not occur. Therefore, we wish to retract the report of the medical event.
"We have notified Bryan Parker of NRC Region III, NRC project manager for the VA's Master Material License, of our plan to withdraw the event declaration."
Notified R3DO (Cameron) and NMSS Events (by 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: 55247
Facility: Callaway
Region: 4 State: MO
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: Jon Chilton
HQ OPS Officer: Bethany Cecere
Region: 4 State: MO
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: Jon Chilton
HQ OPS Officer: Bethany Cecere
Notification Date: 05/10/2021
Notification Time: 21:59 [ET]
Event Date: 05/10/2021
Event Time: 12:50 [CDT]
Last Update Date: 05/10/2021
Notification Time: 21:59 [ET]
Event Date: 05/10/2021
Event Time: 12:50 [CDT]
Last Update Date: 05/10/2021
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
GADDY, VINCENT (R4)
FFD GROUP, (EMAIL)
GADDY, VINCENT (R4)
FFD GROUP, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
EN Revision Imported Date: 6/10/2021
EN Revision Text: FITNESS FOR DUTY - DISCOVERED VULNERABILITY IN FITNESS FOR DUTY PROGRAM
On May 10, 2021, Callaway determined that a violation of 10 CFR 26.4(c) occurred. A licensee employee was assigned to perform Emergency Response Organization (ERO) duties that required that employee to be subject to the Fitness for Duty (FFD) program. However, the individual had been removed from the FFD program. The individual's unescorted access to the plant had been temporarily removed, but the individual was still required to report to the Emergency Operations Facility in accordance with the emergency plan procedures. The individual's ERO qualification has been deactivated. A review determined that this condition did not apply to any other ERO responders. This discovery is reported pursuant to 10 CFR 26.719(b)(4).
The NRC Senior Resident Inspector has been notified of the event.
EN Revision Text: FITNESS FOR DUTY - DISCOVERED VULNERABILITY IN FITNESS FOR DUTY PROGRAM
On May 10, 2021, Callaway determined that a violation of 10 CFR 26.4(c) occurred. A licensee employee was assigned to perform Emergency Response Organization (ERO) duties that required that employee to be subject to the Fitness for Duty (FFD) program. However, the individual had been removed from the FFD program. The individual's unescorted access to the plant had been temporarily removed, but the individual was still required to report to the Emergency Operations Facility in accordance with the emergency plan procedures. The individual's ERO qualification has been deactivated. A review determined that this condition did not apply to any other ERO responders. This discovery is reported pursuant to 10 CFR 26.719(b)(4).
The NRC Senior Resident Inspector has been notified of the event.
Agreement State
Event Number: 55248
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: Ohio State University
Region: 3
City: Columbus State: OH
County:
License #: 02110250037
Agreement: Y
Docket:
NRC Notified By: Michael Rubadue
HQ OPS Officer: Kerby Scales
Licensee: Ohio State University
Region: 3
City: Columbus State: OH
County:
License #: 02110250037
Agreement: Y
Docket:
NRC Notified By: Michael Rubadue
HQ OPS Officer: Kerby Scales
Notification Date: 05/11/2021
Notification Time: 15:46 [ET]
Event Date: 05/10/2021
Event Time: 00:00 [CDT]
Last Update Date: 05/11/2021
Notification Time: 15:46 [ET]
Event Date: 05/10/2021
Event Time: 00:00 [CDT]
Last Update Date: 05/11/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
McCRAW, AARON (R3DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
McCRAW, AARON (R3DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 6/11/2021
EN Revision Text: AGREEMENT STATE REPORT - DOSE TO IMPROPER TREATMENT SITE
The following report was received from the state of Ohio via email:
"A patient was to receive a prescribed dose of 68.92 milliCuries Y-90 TheraSpheres to the left lobe of the liver on 5/10/2021. It was discovered during post treatment imaging on 5/11/2021 that the dose was delivered to the right lobe. The licensee stated the catheter position was verified prior to treatment and the cause of the event is under investigation. The referring physician and patient have been notified."
Ohio Event Number: OH210003
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.
EN Revision Text: AGREEMENT STATE REPORT - DOSE TO IMPROPER TREATMENT SITE
The following report was received from the state of Ohio via email:
"A patient was to receive a prescribed dose of 68.92 milliCuries Y-90 TheraSpheres to the left lobe of the liver on 5/10/2021. It was discovered during post treatment imaging on 5/11/2021 that the dose was delivered to the right lobe. The licensee stated the catheter position was verified prior to treatment and the cause of the event is under investigation. The referring physician and patient have been notified."
Ohio Event Number: OH210003
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: 55255
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Kell West Regional Hospital LLC
Region: 4
City: Wichita Falls State: TX
County:
License #: L-05943
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Jeffrey Whited
Licensee: Kell West Regional Hospital LLC
Region: 4
City: Wichita Falls State: TX
County:
License #: L-05943
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Jeffrey Whited
Notification Date: 05/12/2021
Notification Time: 16:45 [ET]
Event Date: 05/10/2021
Event Time: 00:00 [CDT]
Last Update Date: 05/12/2021
Notification Time: 16:45 [ET]
Event Date: 05/10/2021
Event Time: 00:00 [CDT]
Last Update Date: 05/12/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
GADDY, VINCENT (R4DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
GADDY, VINCENT (R4DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 6/11/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following was received from the Texas Department of State Health Services (the Agency) via email:
"On May 12, 2021, the Agency was notified by the licensee that a medical event had occurred on May 10, 2021. The event involved a prostate seed treatment using cesium - 131 seeds. The licensee reported that after the implant procedure they discovered that a large portion of the seeds had been implanted in the wrong location. The licensee stated the seeds that were misplaced ended up in mostly fatty tissue and they do not believe any adverse effects will be experienced by the patient. The licensee could not provide specific information on what percent of the prescribe dose had been received by the targeted tissue. The event and its cause is currently under investigation by the licensee. The prescribing physician has been made aware of the event and is notifying the patient. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: I-9848
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.
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following was received from the Texas Department of State Health Services (the Agency) via email:
"On May 12, 2021, the Agency was notified by the licensee that a medical event had occurred on May 10, 2021. The event involved a prostate seed treatment using cesium - 131 seeds. The licensee reported that after the implant procedure they discovered that a large portion of the seeds had been implanted in the wrong location. The licensee stated the seeds that were misplaced ended up in mostly fatty tissue and they do not believe any adverse effects will be experienced by the patient. The licensee could not provide specific information on what percent of the prescribe dose had been received by the targeted tissue. The event and its cause is currently under investigation by the licensee. The prescribing physician has been made aware of the event and is notifying the patient. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: I-9848
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.