Event Notification Report for April 18, 2023

AGREEMENT STATE REPORT - POSSIBLE OVEREXPOSURE DOSE FOR AN EMBRYO/FETUS OF A DECLARED PREGNANT WOMAN

The following was received from the South Carolina Department of Health and Environmental Control (the Department) via email:

"On 03/24/23, at 1446 [EDT], the Department was notified by the licensee of a dose more than the dose limit for an embryo/fetus of a declared pregnant woman. A written report was also submitted on 03/24/23. The employee is a Technical Assistant for mobile [positron emission tomography/computed tomography] (PET/CT) operations and is not directly involved with handling radioactive material. The estimated dose reported was 1145 mrem [deep dose equivalent] (DDE) for a one-month period, the cumulative dose was 1239 mrem DDE. The licensee's report indicated it is possible that the badge may have been in the PET/CT scanner room during patient scans, but the employee could not recall that this ever happened. The licensee also reported the chest and control badges showed no elevated readings; only the fetal badge. The licensee's corrective actions included discussing with the employee the importance of making sure the badge is never left in a radiation area, and while at work, the badge is always worn properly for the entire day. Proper storage of badges next to the control badge was also discussed. The Department performed an on-site investigation on 03/29/23, and the information obtained during the on-site investigation was consistent with the licensee's written report. This event is considered closed."

South Carolina Department of Health and Environmental Control report no.: SC230008

AGREEMENT STATE - DAMAGED RADIOGRAPHY GUIDE TUBE PREVENTING RETRACTION OF SOURCE

The following information was provided by the Texas Department of State Health Services (the Agency) via email:

"On April 10, 2023, the licensee reported to the Agency that on April 7, 2023, one of its QSA Delta 880 industrial radiography exposure devices (camera) had fallen approximately three feet onto the source guide tube at a job site in Orla, Texas. The camera severed the guide tube and the source pigtail was disconnected from the drive cable. The source was 72 curies of iridium-192. A boundary was set at 2 millirem by the radiographers and an individual authorized on their license was dispatched to the site and retrieved the source. The retriever's dosimeter indicated a whole-body dose of 2.6 rem. The licensee has reported initial calculations for the retriever's hand dose to be 385.9 millirem. The two radiographer's self-reading pocket dosimeters indicated doses of 180 and 150 millirem. All of the equipment is being sent to the manufacturer for evaluation. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: I-10007

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.

SINGLE TRAIN OF LOW PRESSURE CORE SPRAY INOPERABLE

The following information was provided by the licensee via email:

"At 0246 CDT on April 17, 2023, it was discovered that the single train low pressure core spray system was inoperable. Due to this inoperability, the system was in a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). All other emergency core cooling systems remained operable during this time period.

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

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

LaSalle Unit 1 is in a 7 day limiting condition for operation.