Event Notification Report for May 18, 2023

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.

AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by Arizona Department of Health Services (the Department) via email:

"The Department received notification from the licensee about a medical event involving Y-90 Theraspheres. A patient was prescribed 27.72 mCi but was delivered 17.38 mCi, a percent dose delivered of approximately 63 percent. The Department has requested additional information and continues to investigate the event.

"Additional information will be provided as it is received in accordance with SA-300."

Arizona incident number: 23-008

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."

FITNESS-FOR-DUTY VIOLATION

The following information was provided by the licensee via email:

"On May 16, 2023, it was determined that a licensed operator violated the station's FFD policy. The employee's unescorted access at South Texas has been terminated. This event was determined to be reportable under 10 CFR 26.719(b)(2)(ii).

"The NRC resident inspector has been notified."

FITNESS-FOR-DUTY VIOLATION

The following information was provided by the licensee via email:

On May 17, 2023, at 0649 PDT, it was determined that a prohibited item had been found inside the protected area.

The NRC Resident Inspector has been notified.