Event Notification Report for May 24, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/23/2023 - 05/24/2023
Agreement State
Event Number: 56540
Rep Org: Colorado Dept of Health
Licensee: University of Colorado Hospital
Region: 4
City: Aurora State: CO
County:
License #: CO 828-01
Agreement: Y
Docket:
NRC Notified By: Heather Gilbert
HQ OPS Officer: Ian Howard
Licensee: University of Colorado Hospital
Region: 4
City: Aurora State: CO
County:
License #: CO 828-01
Agreement: Y
Docket:
NRC Notified By: Heather Gilbert
HQ OPS Officer: Ian Howard
Notification Date: 05/25/2023
Notification Time: 16:40 [ET]
Event Date: 05/24/2023
Event Time: 13:00 [MDT]
Last Update Date: 05/25/2023
Notification Time: 16:40 [ET]
Event Date: 05/24/2023
Event Time: 13:00 [MDT]
Last Update Date: 05/25/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Vossmar, Patricia (R4DO)
NMSS_Events_Notification, (EMAIL)
Vossmar, Patricia (R4DO)
NMSS_Events_Notification, (EMAIL)
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was provided by the Colorado Department of Health via email:
"On May 24, 2023, the Radiation Safety Officer of the University of Colorado Hospital (RAML [Radioactive Material License] 828-01) reported a medical event. The medical event occurred during the administration of Y-90 TheraSphere treatment that took place in the afternoon on Wednesday, May 24, 2023. During the administration, there appeared to be an obstruction in the catheter's line preventing the target from receiving the intended dose. The obstruction was noticed early in the procedure and it's estimated only 5 to10 percent of dose went to the target organ. After the obstruction was observed, the catheter was removed from the patient and the rest of the dose was not administered. This event is similar to an event at the same hospital on May 18, 2023 (CO230012) which occurred with a different AU [authorized user]. The TheraSpheres were from the same batch. The licensee is pausing Therasphere administrations from the same lot number. We are still waiting on additional information from the hospital about the investigation."
Event Report ID No.: CO230014
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 Colorado Department of Health via email:
"On May 24, 2023, the Radiation Safety Officer of the University of Colorado Hospital (RAML [Radioactive Material License] 828-01) reported a medical event. The medical event occurred during the administration of Y-90 TheraSphere treatment that took place in the afternoon on Wednesday, May 24, 2023. During the administration, there appeared to be an obstruction in the catheter's line preventing the target from receiving the intended dose. The obstruction was noticed early in the procedure and it's estimated only 5 to10 percent of dose went to the target organ. After the obstruction was observed, the catheter was removed from the patient and the rest of the dose was not administered. This event is similar to an event at the same hospital on May 18, 2023 (CO230012) which occurred with a different AU [authorized user]. The TheraSpheres were from the same batch. The licensee is pausing Therasphere administrations from the same lot number. We are still waiting on additional information from the hospital about the investigation."
Event Report ID No.: CO230014
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.
Power Reactor
Event Number: 56539
Facility: Palo Verde
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Lorraine Weaver
HQ OPS Officer: Ian Howard
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Lorraine Weaver
HQ OPS Officer: Ian Howard
Notification Date: 05/24/2023
Notification Time: 19:58 [ET]
Event Date: 05/24/2023
Event Time: 07:10 [MST]
Last Update Date: 05/24/2023
Notification Time: 19:58 [ET]
Event Date: 05/24/2023
Event Time: 07:10 [MST]
Last Update Date: 05/24/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Vossmar, Patricia (R4DO)
FFD Group, (EMAIL)
Vossmar, Patricia (R4DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS-FOR-DUTY REPORT
The following information was provided by the licensee via phone and email:
"On May 24th, 2023, at approximately 0710 MDT, a non-licensed contract supervisor had a confirmed positive for alcohol during a for-cause fitness-for-duty test. The individual's plant access has been terminated in accordance with station procedures.
"The NRC Resident Inspector has been notified."
The following information was provided by the licensee via phone and email:
"On May 24th, 2023, at approximately 0710 MDT, a non-licensed contract supervisor had a confirmed positive for alcohol during a for-cause fitness-for-duty test. The individual's plant access has been terminated in accordance with station procedures.
"The NRC Resident Inspector has been notified."