Event Notification Report for May 17, 2023

AGREEMENT STATE REPORT - FAILED SHUTTER

The following information was provided by the North Dakota Department of Health, Radiation Control Program via email:

"On 5/8/2023, Minn-Dak Farmers Cooperative in Wahpeton, ND, had an equipment failure on a fixed nuclear gauge (Thermo MeasureTech Model No. 7062) with a 46.7 millicurie Cs-137 sealed source (General Radioisotope Products, Inc. Model No. 850233). The licensee was performing the required routine shutter checks and it was found that shutter on the gauge listed above failed to fully close. There was no visual damage to the shutter, gauge or source at the time of the shutter check. Licensee is in contact with the service provider Vega to replace the gauge."

POTENTIAL MEDICAL EVENT

The following information was provided by the licensee via phone and email:

"In accordance with 10 CFR 35.3045, [Henry Ford Hospital is] reporting a potential medical event.

"On May 8, 2023, a patient was treated with Y-90 TheraSpheres. The total activity prescribed in the written directive was 11.5 mCi to the left lobe of the liver and 11.37 mCi was delivered (99.2 percent). The therapeutic dose was prescribed to be delivered to segment 4 of the left lobe of the liver. During treatment, the position of the catheter was verified and was determined by the physician to be in the correct position. However, post-treatment bremsstrahlung imaging reviewed today on 5/9/2023 indicated some activity was shunted unexpectedly to segments 2 and 3 of the left lobe of the liver. Based on preliminary calculations, this discrepancy could be categorized as a medical event."

* * * RETRACTION FROM ALAN JACKSON TO BILL GOTT AT 0907 EDT ON 05/10/2023 * * *

The following information was provided by the licensee via phone:

Since the exposure was due to shunting, the licensee determined that this event is not reportable in accordance with the licensing guide. This event is being retracted.

Notified R3DO (Feliz-Adorno), NMSS (Rivera-Capella), and NMSS Events Notification.

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 - MEDICAL EVENT

The following information was received via email from the Texas Dept. of State Health Services (the Agency):

"On May 9, 2023, the Agency was notified by the licensee that a medical event occurred earlier that day. The licensee stated a patient was prescribed two doses of SIR-Spheres yittrium-90 (Y-90). After the procedure, it was determined that the patient received doses differed from the prescribed doses by more than 20 percent. The patient was prescribed doses of 14.5 mCi and 21.7 mCi. The patient received 5.3 mCi (for the syringe dose of 14.2 mCi) and 12.31 mCi (for the syringe dose of 21.5 mCi). Delivered doses differed by 37.3 percent and 57.2 percent respectively. The prescribing physician and patient were notified of the error. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: 10017

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.

FITNESS FOR DUTY REPORT

The following information was provided by the licensee via phone:

"A licensed operator failed a test specified by the FFD testing program. The individual's site access has been terminated.

"The NRC Resident Inspector has been notified."

EMERGENCY EXHAUST INOPERABLE

The following information was provided by the licensee via phone and email:

"At 1127 CDT on 5/16/2023, during the reperformance of test procedure 'STS PE-006, Charcoal Adsorber In-Place Leak Test' due to a failure from the previous day, both trains of emergency exhaust were rendered inoperable due to incorrect performance of the procedure. Performers incorrectly de-energized the humidity control heating coil for the unit not under test, rendering it inoperable. This issue was identified and rectified at 1138 CDT on 5/16/2023, exiting the LCO [limiting condition of operation] for both trains inoperable at that time. There was no impact to the health and safety of the public."