Event Notification Report for May 27, 2021

EN Revision Imported Date: 5/27/2021

EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following was received from the state of Minnesota via email:

"Only 48.63 Gy was delivered out of the 120 Gy prescribed to the patient [liver]. It appears that 1.8 GBq of the prescribed 2.95 GBq of Y-90 microspheres remained in the delivery device after removal from the patient. Only 1.15 GBq was delivered."


Minnesota Event Report ID: MN-21-0003


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 Imported Date: 5/27/2021

EN Revision Text: PATIENT UNDERDOSE

The following e-mail was received from the Radiation Safety Officer (RSO) at Kootenai Health:

"A misadministration occurred at Kootenai Health in the Interventional Radiology Lab (ID 83814) during a Therasphere Y-90 Microsphere treatment. The prescribed dose was 66.36 mCi to segment 8 of the liver. The microspheres infusion started at 0943 PST when the micropsheres became visually clumped in the tubing of the administration set (distal to the box, prior to the microcatheter connection). Troubleshooting methods were performed, but the microspheres did not move through the tubing with multiple saline flush attempts. The infusion was aborted at 1016 PST. The room was surveyed per protocol and there was no contamination. The jar containing the tubing and microcatheter were measured per protocol. Calculations determined the patient received 12.8 mCi which was 20 percent of the prescribed dose. The RSO was notified at 1058 PST, the referring physician [was notified] at 1128 PST, and the patient [was notified] at 1150 PST."

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 Imported Date: 5/27/2021

EN Revision Text: UNIT 2 CONTAINMENT LOCAL LEAK RATE AND AS-FOUND INTEGRATED OVERALL LEAKAGE RATE EXCEEDED ACCEPTANCE CRITERIA

"At 1751 EDT on May 25, 2021, it was determined the local leak rate test (LLRT) for the 2EMF-IN containment penetration did not meet 10 CFR 50 Appendix J requirements for both the inboard and outboard containment isolation valves (2MISV5230 and 2MISV5231). The LLRT was performed during the previous refueling outage at which time primary containment was not required to be operable. The leakage assigned to the penetration also resulted in total leakage exceeding the allowed overall leakage. The valves were repaired and retested satisfactory prior to entering the mode of applicability, This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A),

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

EN Revision Imported Date: 5/27/2021

EN Revision Text: REPORT OF OFFSITE NOTIFICATION

"Event meets ACD2-RG-044 App. B N.1 'The licensee shall notify the NRC Operations Center of any event or situation, related to the health and safety of the public or onsite personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made. Such an event may include an on-site fatality or inadvertent release of radioactively contaminated materials.'

"Received preliminary notification from TestAmerica Colorado that there was an exceedance of the Total Suspended Solids NPDES [National Pollution Discharge Elimination System] permit limit at Outfall 013. This was not unexpected with the current state of the settling pond above Outfall 013. An Ohio EPA [OEPA] 24 Hour non-compliance notification form was filled out and sent it to our OEPA NPDES inspector.

"Notification concurrent to the OEPA notification."