Event Notification Report for June 14, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/13/2023 - 06/14/2023
Agreement State
Event Number: 56577
Rep Org: WA Office of Radiation Protection
Licensee: Providence Sacred Heart Medical Ctr
Region: 4
City: Spokane State: WA
County:
License #: WN-M031
Agreement: Y
Docket:
NRC Notified By: Boris Tsenov
HQ OPS Officer: Ernest West
Licensee: Providence Sacred Heart Medical Ctr
Region: 4
City: Spokane State: WA
County:
License #: WN-M031
Agreement: Y
Docket:
NRC Notified By: Boris Tsenov
HQ OPS Officer: Ernest West
Notification Date: 06/15/2023
Notification Time: 19:53 [ET]
Event Date: 06/14/2023
Event Time: 00:00 [PDT]
Last Update Date: 06/15/2023
Notification Time: 19:53 [ET]
Event Date: 06/14/2023
Event Time: 00:00 [PDT]
Last Update Date: 06/15/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Warnick, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Warnick, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DOSE MISADMINISTRATION
The following information was provided by the Washington State Office of Radiation Protection via email:
"On 6/14/2023, a dose misadministration occurred during high dose rate brachytherapy at the Sacred Heart (SH) Radiotherapy Department. The authorized user (AU) intended for 15 Gy to be delivered in three [separate] 5 Gy fractions, but it was planned and delivered in a single 15 Gy treatment. The incident was discovered around 1630 [PDT] the same day. The AU has informed the patient and the referring physician.
"The SH medical physicist noted that 13 Gy in a single fraction is an effective treatment for the patient's condition (keloids on and around both ears). The 15 Gy was delivered to the keloid surface, and skin tolerance in a single fraction is greater than 25 Gy.
"Follow up with the patient will be perform in the next few days and ongoing. No other exposure to staff is reported."
WA incident number: WA-23-009
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 Washington State Office of Radiation Protection via email:
"On 6/14/2023, a dose misadministration occurred during high dose rate brachytherapy at the Sacred Heart (SH) Radiotherapy Department. The authorized user (AU) intended for 15 Gy to be delivered in three [separate] 5 Gy fractions, but it was planned and delivered in a single 15 Gy treatment. The incident was discovered around 1630 [PDT] the same day. The AU has informed the patient and the referring physician.
"The SH medical physicist noted that 13 Gy in a single fraction is an effective treatment for the patient's condition (keloids on and around both ears). The 15 Gy was delivered to the keloid surface, and skin tolerance in a single fraction is greater than 25 Gy.
"Follow up with the patient will be perform in the next few days and ongoing. No other exposure to staff is reported."
WA incident number: WA-23-009
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.
Non-Agreement State
Event Number: 56573
Rep Org: Reid Health
Licensee: Reid Health
Region: 3
City: Richmond State: IN
County:
License #: 13-03284-02
Agreement: N
Docket:
NRC Notified By: Mary Ellen Weisner
HQ OPS Officer: Adam Koziol
Licensee: Reid Health
Region: 3
City: Richmond State: IN
County:
License #: 13-03284-02
Agreement: N
Docket:
NRC Notified By: Mary Ellen Weisner
HQ OPS Officer: Adam Koziol
Notification Date: 06/14/2023
Notification Time: 10:12 [ET]
Event Date: 06/14/2023
Event Time: 07:00 [EDT]
Last Update Date: 06/14/2023
Notification Time: 10:12 [ET]
Event Date: 06/14/2023
Event Time: 07:00 [EDT]
Last Update Date: 06/14/2023
Emergency Class: Non Emergency
10 CFR Section:
20.1906(d)(1) - Surface Contam Levels > Limits
10 CFR Section:
20.1906(d)(1) - Surface Contam Levels > Limits
Person (Organization):
Peterson, Hironori (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Peterson, Hironori (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
NON-AGREEMENT STATE - SURFACE CONTAMINATION ON OUTSIDE OF PACKAGE
The following is a summary of information provided by the licensee via telephone:
On 6/14/23 around 0700 EDT, the licensee received three packages containing F-18 sources. Swipe readings on the packages revealed 42333 counts per minute (cpm), 12857 cpm, and 267 cpm. The packages had slightly elevated radiation readings. The radiation safety officer (RSO) and supplier were notified. There was no contamination found inside of the packaging, and the F-18 doses were double sealed without damage. Swipe readings were taken along the delivery path, but no spread of contamination to public spaces was detected. The affected packages were placed in a radiation storage area pending disposal.
The following is a summary of information provided by the licensee via telephone:
On 6/14/23 around 0700 EDT, the licensee received three packages containing F-18 sources. Swipe readings on the packages revealed 42333 counts per minute (cpm), 12857 cpm, and 267 cpm. The packages had slightly elevated radiation readings. The radiation safety officer (RSO) and supplier were notified. There was no contamination found inside of the packaging, and the F-18 doses were double sealed without damage. Swipe readings were taken along the delivery path, but no spread of contamination to public spaces was detected. The affected packages were placed in a radiation storage area pending disposal.
Power Reactor
Event Number: 56576
Facility: Byron
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: John Conroy
HQ OPS Officer: Adam Koziol
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: John Conroy
HQ OPS Officer: Adam Koziol
Notification Date: 06/15/2023
Notification Time: 09:35 [ET]
Event Date: 06/14/2023
Event Time: 09:26 [CDT]
Last Update Date: 06/15/2023
Notification Time: 09:35 [ET]
Event Date: 06/14/2023
Event Time: 09:26 [CDT]
Last Update Date: 06/15/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Peterson, Hironori (R3DO)
FFD Group, (EMAIL)
Peterson, Hironori (R3DO)
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 | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS-FOR-DUTY REPORT
The following is a summary of information provided by the licensee via email:
A non-licensed, non-supervisory employee was identified bringing a prohibited item into the protected area. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
The following is a summary of information provided by the licensee via email:
A non-licensed, non-supervisory employee was identified bringing a prohibited item into the protected area. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.