Event Notification Report for January 11, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/10/2023 - 01/11/2023
Hospital
Event Number: 56309
Rep Org: Georgetown Hospital
Licensee: Georgetown Hospital
Region: 1
City: Washington State: DC
County:
License #: 08-30577-01
Agreement: N
Docket:
NRC Notified By: Matt Williams
HQ OPS Officer: Mike Stafford
Licensee: Georgetown Hospital
Region: 1
City: Washington State: DC
County:
License #: 08-30577-01
Agreement: N
Docket:
NRC Notified By: Matt Williams
HQ OPS Officer: Mike Stafford
Notification Date: 01/12/2023
Notification Time: 08:26 [ET]
Event Date: 01/11/2023
Event Time: 13:45 [EST]
Last Update Date: 01/12/2023
Notification Time: 08:26 [ET]
Event Date: 01/11/2023
Event Time: 13:45 [EST]
Last Update Date: 01/12/2023
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):
Jackson, Don (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Jackson, Don (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MEDICAL EVENT - PATIENT UNDERDOSE
The following information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
On January 11, 2023, a patient was administered a Y-90 Therasphere treatment to segments 5 and 8 of the liver. The prescribed dose was intended to be 1.377 GBq. The patient only received a dose of 0.903 GBq. At the time of notification, the licensee suspects that a low flow rate caused an occlusion in the catheter, resulting in less than the prescribed dose of Y-90 being administered to the patient. There were no reported adverse effects for the patient.
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.
The following information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
On January 11, 2023, a patient was administered a Y-90 Therasphere treatment to segments 5 and 8 of the liver. The prescribed dose was intended to be 1.377 GBq. The patient only received a dose of 0.903 GBq. At the time of notification, the licensee suspects that a low flow rate caused an occlusion in the catheter, resulting in less than the prescribed dose of Y-90 being administered to the patient. There were no reported adverse effects for the patient.
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.
Non-Power Reactor
Event Number: 56308
Rep Org: Reed College (REED)
Licensee: Reed Institute
Region: 0
City: Portland State: OR
County: Multnomah
License #: R-112
Agreement: Y
Docket: 05000288
NRC Notified By: Jerry Newhouse
HQ OPS Officer: Ernest West
Licensee: Reed Institute
Region: 0
City: Portland State: OR
County: Multnomah
License #: R-112
Agreement: Y
Docket: 05000288
NRC Notified By: Jerry Newhouse
HQ OPS Officer: Ernest West
Notification Date: 01/11/2023
Notification Time: 17:21 [ET]
Event Date: 01/11/2023
Event Time: 14:10 [PST]
Last Update Date: 01/11/2023
Notification Time: 17:21 [ET]
Event Date: 01/11/2023
Event Time: 14:10 [PST]
Last Update Date: 01/11/2023
Emergency Class: Non Emergency
10 CFR Section:
10 CFR Section:
Person (Organization):
Geoffrey Wertz (NRR)
Michael Takacs (NRR)
Geoffrey Wertz (NRR)
Michael Takacs (NRR)
TECHNICAL SPECIFICATION VIOLATION
The following information was provided by the licensee via email:
"During irradiated fuel movement, the exhaust fan stopped functioning. A staff member in the area saw it spark, smelled a slight acrid odor, and the fan shut down. As of 1429 [PST], the fuel element was returned to its original position and the reactor is secured. Maintenance staff is beginning work on the fan motor. Notified the Nuclear Regulatory Commission Project Manager."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
This event violated technical specification 3.4 for ventilation.
The following information was provided by the licensee via email:
"During irradiated fuel movement, the exhaust fan stopped functioning. A staff member in the area saw it spark, smelled a slight acrid odor, and the fan shut down. As of 1429 [PST], the fuel element was returned to its original position and the reactor is secured. Maintenance staff is beginning work on the fan motor. Notified the Nuclear Regulatory Commission Project Manager."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
This event violated technical specification 3.4 for ventilation.
Agreement State
Event Number: 56319
Rep Org: PA Bureau of Radiation Protection
Licensee: Geisinger Health System
Region: 1
City: Danville State: PA
County:
License #: PA-0006
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Ian Howard
Licensee: Geisinger Health System
Region: 1
City: Danville State: PA
County:
License #: PA-0006
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Ian Howard
Notification Date: 01/20/2023
Notification Time: 15:46 [ET]
Event Date: 01/11/2023
Event Time: 00:00 [EST]
Last Update Date: 01/20/2023
Notification Time: 15:46 [ET]
Event Date: 01/11/2023
Event Time: 00:00 [EST]
Last Update Date: 01/20/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Ambrosini, Josephine (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Ambrosini, Josephine (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was provided by the Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (the Department) via email:
"On January 20, 2023 the licensee informed the Department of an under-dose incident involving yttrium-90 (Y-90) TheraSpheres. It is reportable per 10 CFR 35.3045(a)(1).
"On January 11, 2023 an Authorized User (AU) in Interventional Radiology was attempting to treat a patient with 45.4 mCi of yttrium-90 TheraSphere. The AU could not get the spheres to infuse. After consultation with the manufacturer (Boston Scientific), they decided on aborting the procedure. It was determined the patient received zero activity and all the radioactivity from the spheres remained inside the treatment vial. The patient and referring physician have been informed. The Department is currently in contact with the licensee and will update this event as soon as more information is provided."
Event Report ID No: PA230005
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.
The following information was provided by the Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (the Department) via email:
"On January 20, 2023 the licensee informed the Department of an under-dose incident involving yttrium-90 (Y-90) TheraSpheres. It is reportable per 10 CFR 35.3045(a)(1).
"On January 11, 2023 an Authorized User (AU) in Interventional Radiology was attempting to treat a patient with 45.4 mCi of yttrium-90 TheraSphere. The AU could not get the spheres to infuse. After consultation with the manufacturer (Boston Scientific), they decided on aborting the procedure. It was determined the patient received zero activity and all the radioactivity from the spheres remained inside the treatment vial. The patient and referring physician have been informed. The Department is currently in contact with the licensee and will update this event as soon as more information is provided."
Event Report ID No: PA230005
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.