Event Notification Report for April 10, 2023

MEDICAL EVENT - DOSE RECEIVED GREATER THAN PRESCRIBED

The following information is a synopsis of information provided by the licensee:

This event occurred at Community Health Network, North Hospital on 4/10/2023 and the error was discovered at approximately 12:00 p.m. [EDT].

This procedure involved a split dose, so the patient received two separate doses in two separate locations in the liver. Hospital personnel use a spreadsheet to help with calculations while drawing the dose and to determine the administered activity after the procedure. Hospital personnel had two spreadsheets due to the split dose. When the radiation safety officer (RSO) was completing the worksheets after the procedure, she noticed that the Grays (Gy) delivered on one of the doses was much higher than anticipated. When the RSO reviewed the worksheet, she realized that she had a typo in the prescribed activity in the worksheet and did not catch it prior to administration. Typically, the physician will fill out the written directive with giga-becquerel (GBq) and the RSO would enter millicuries (mCi) in parentheses, since the dose calibrator reads in mCi. Although the worksheet converts dose, this helps as a double check when completing the written directive. In this case, the RSO had not entered mCi, only GBq and did not catch that the second dose was much higher than the prescribed activity. If the RSO had entered the mCi on the written directive (WD) as per usual, she would have caught that this dose was higher than prescribed.

Initial corrective action will be to enter both GBq and mCi on the WD and give both versions of activity when doing the patient identification at the beginning of the procedure with the physician.

The physician was notified immediately and she was notifying the patient. At this time there is not expected to be any detrimental effects to the patient.

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

The prescribed first dose was 43.2 mCi of Y-90 SIR-Spheres, 63.2 mCi was delivered. The prescribed second dose was 18.9 mCi and 20.8 mCi was delivered.

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 REPORT - SHIPMENT DELAYED AND SOURCES HELD AT INTERIM LOCATION

The following information was provided by the California Radiation Control Program via email:

"Industrial Nuclear Company (INC) [located in California] shipped three nominal 103 Curie Ir-192 radiography sources to Miami for export to a customer in Venezuela on 9/27/22. The sources did not reach the Venezuelan customer. The sources were reported missing by INC on 4/10/23 [the sources were never 'lost' as their whereabouts were known to be in custody]. The sources have been recovered from a common carrier warehouse in the Miami area by the Florida Radiation Control Bureau and Florida law enforcement on 4/14/23.

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

A previous notification of this matter was made to the Headquarters Operations Officer (HOO) by the Florida Radiation Control Program on 4/10/23. On 4/10/2023 at 1300 EDT, the HOO also received a phone call from INC regarding a potentially abandoned radioactive source that was originally intended to be shipped to Venezuela but was in possession of the common carrier in Doral, FL. The state of Florida provided preliminary information on the incident and will provide additional information as it becomes available.

THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

AUTOMATIC REACTOR TRIP

The following information was provided by the licensee via email:

"At 0048 EDT on 4/10/2023, with Unit 3 in Mode 1 at 18 percent power, the reactor automatically tripped due to low reactor coolant flow due to voltage decaying to the reactor coolant pumps during main generator testing activities. The trip was not complex, with all safety-related systems responding normally post-trip.

"Operations responded and stabilized the plant. Decay heat is being removed by discharging steam via steam generator power operated relief valves to atmosphere. Units 1, 2, and 4 are not affected.

"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).

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