Event Notification Report for July 11, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/10/2023 - 07/11/2023
Hospital
Event Number: 56619
Rep Org: Henry Ford Hospital
Licensee: Henry Ford Hospital
Region: 3
City: Detroit State: MI
County:
License #: 21-04109-16
Agreement: N
Docket:
NRC Notified By: Alan Jackson
HQ OPS Officer: Ian Howard
Licensee: Henry Ford Hospital
Region: 3
City: Detroit State: MI
County:
License #: 21-04109-16
Agreement: N
Docket:
NRC Notified By: Alan Jackson
HQ OPS Officer: Ian Howard
Notification Date: 07/12/2023
Notification Time: 12:13 [ET]
Event Date: 07/11/2023
Event Time: 17:00 [EDT]
Last Update Date: 07/12/2023
Notification Time: 12:13 [ET]
Event Date: 07/11/2023
Event Time: 17:00 [EDT]
Last Update Date: 07/12/2023
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(2) - Dose > Specified Eff Limits
10 CFR Section:
35.3045(a)(2) - Dose > Specified Eff Limits
Person (Organization):
Stoedter, Karla (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Fisher, Jennifer (NMSS)
Stoedter, Karla (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Fisher, Jennifer (NMSS)
MEDICAL EVENT - DOSE MISADMINISTRATION
The following information was provided by the licensee via phone:
On July 11, 2023, at 1700 EDT, an intravascular brachytherapy treatment was delivered to the wrong treatment site. The original dose of 23 Gy was intended for a different part of the vasculature system. The brachytherapy device made by Best Vascular is a Beta-Catch (model # 5ICW-2) containing 3.62 GBq of Sr/Y-90. Physicians expect that there will be no permanent damage to any of the patient's organs.
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 licensee via phone:
On July 11, 2023, at 1700 EDT, an intravascular brachytherapy treatment was delivered to the wrong treatment site. The original dose of 23 Gy was intended for a different part of the vasculature system. The brachytherapy device made by Best Vascular is a Beta-Catch (model # 5ICW-2) containing 3.62 GBq of Sr/Y-90. Physicians expect that there will be no permanent damage to any of the patient's organs.
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: 56618
Facility: North Anna
Region: 2 State: VA
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: Marc Hofmann
HQ OPS Officer: Kerby Scales
Region: 2 State: VA
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: Marc Hofmann
HQ OPS Officer: Kerby Scales
Notification Date: 07/11/2023
Notification Time: 17:42 [ET]
Event Date: 07/11/2023
Event Time: 15:30 [EDT]
Last Update Date: 07/11/2023
Notification Time: 17:42 [ET]
Event Date: 07/11/2023
Event Time: 15:30 [EDT]
Last Update Date: 07/11/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| 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 |
OFFSITE NOTIFICATION
The following information was provided by the licensee via email:
"At 1530 [EDT] on 7/11/2023, North Anna Power Station notified the Virginia Department of Environmental Quality (DEQ) that a small volume of filtered/purified water potentially discharged into Lake Anna from a leak from a reverse osmosis unit. The leak did not follow the normal release path for discharge through outfall 013. No environmental impact associated with this leak was observed or would be expected because the water in question is cleaner than the lake water, and would have met all discharge requirements for outfall 013.
"The NRC Resident Inspector was notified.
"This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi)."
The following information was provided by the licensee via email:
"At 1530 [EDT] on 7/11/2023, North Anna Power Station notified the Virginia Department of Environmental Quality (DEQ) that a small volume of filtered/purified water potentially discharged into Lake Anna from a leak from a reverse osmosis unit. The leak did not follow the normal release path for discharge through outfall 013. No environmental impact associated with this leak was observed or would be expected because the water in question is cleaner than the lake water, and would have met all discharge requirements for outfall 013.
"The NRC Resident Inspector was notified.
"This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi)."