Event Notification Report for June 02, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/01/2023 - 06/02/2023
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
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
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Vossmar, Patricia (R4DO)
NMSS_Events_Notification, (EMAIL)
Event Text
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.
Fuel Cycle Facility
Event Number: 56550
Facility: Louisiana Energy Services
RX Type:
Comments:
Uranium Enrichment Facility
Gas Centrifuge Facility
Region: 2
City: Eunice State: NM
County: Lea
License #: SNM-2010
Docket: 70-3103
NRC Notified By: Dirk Lundgren
HQ OPS Officer: Brian P. Smith
Notification Date: 06/01/2023
Notification Time: 20:16 [ET]
Event Date: 06/01/2023
Event Time: 02:39 [MDT]
Last Update Date: 06/01/2023
Emergency Class: Non Emergency
10 CFR Section:
70.50(b)(2) - Safety Equipment Failure
Person (Organization):
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
PARTIAL LOSS OF CRITICALITY ACCIDENT ALARM SYSTEM
The following information was provided by the licensee via email:
"On June 1, 2023, during inclement weather, a Phase 2 CAAS [Criticality Accident Alarm System] detector fault was received. Troubleshooting efforts indicated two CAAS nodes are impacted and SBM1005 [Process Services Corridor] was evacuated. The affected detectors are located in the north end of the SBM1005 Process Services Corridor. Compensatory measures are implemented in the affected area to support maintenance troubleshooting efforts.
"UUSA is reporting this event per 10 CFR 70.50(b)(2)."