Event Notification Report for February 07, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/06/2024 - 02/07/2024
Power Reactor
Event Number: 56952
Facility: Hope Creek
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: Yousuf Khaled
HQ OPS Officer: Natalie Starfish
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: Yousuf Khaled
HQ OPS Officer: Natalie Starfish
Notification Date: 02/08/2024
Notification Time: 12:40 [ET]
Event Date: 02/07/2024
Event Time: 16:00 [EST]
Last Update Date: 02/08/2024
Notification Time: 12:40 [ET]
Event Date: 02/07/2024
Event Time: 16:00 [EST]
Last Update Date: 02/08/2024
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Lilliendahl, Jon (R1DO)
FFD Group, (EMAIL)
Lilliendahl, Jon (R1DO)
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 |
FITNESS FOR DUTY PROGRAMATIC ISSUE
The following information was provided by the licensee via email:
"A programmatic vulnerability, failure, or degradation was discovered within the fitness for duty (FFD) program that may permit undetected drug or alcohol use or abuse by individuals within the protected area, or by individuals who are assigned to perform duties that require them to be subject to the FFD program.
"Public and plant safety have not been affected."
The NRC Resident Inspector was notified.
The following information was provided by the licensee via email:
"A programmatic vulnerability, failure, or degradation was discovered within the fitness for duty (FFD) program that may permit undetected drug or alcohol use or abuse by individuals within the protected area, or by individuals who are assigned to perform duties that require them to be subject to the FFD program.
"Public and plant safety have not been affected."
The NRC Resident Inspector was notified.
Agreement State
Event Number: 57048
Rep Org: Arkansas Department of Health
Licensee: Central AR Rad Therapy Institute
Region: 4
City: Little Rock State: AR
County:
License #: CARTI ARK-0954-02200
Agreement: Y
Docket:
NRC Notified By: Susan Elliott
HQ OPS Officer: Tenisha Meadows
Licensee: Central AR Rad Therapy Institute
Region: 4
City: Little Rock State: AR
County:
License #: CARTI ARK-0954-02200
Agreement: Y
Docket:
NRC Notified By: Susan Elliott
HQ OPS Officer: Tenisha Meadows
Notification Date: 03/25/2024
Notification Time: 14:04 [ET]
Event Date: 02/07/2024
Event Time: 00:00 [CDT]
Last Update Date: 04/25/2024
Notification Time: 14:04 [ET]
Event Date: 02/07/2024
Event Time: 00:00 [CDT]
Last Update Date: 04/25/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/26/2024
EN Revision Text: AGREEMENT STATE REPORT - Y-90 MICROSPHERE MISADMINISTRATION
The following information was provided by the Arkansas Department of Health, Radiation Control Radioactive Material Program (the Agency) via email:
"The radiation safety officer for Central Arkansas Radiation Therapy Institute (CARTI) contacted the Agency on March 21, 2024, to advise of a yttrium-90 (Y-90) microsphere therapy administration in which the patient received 20 percent greater than the prescribed dose. The administration occurred on February 7, 2024. Treatment was only to one side of the liver. The amount was localized to the liver. The physician felt the delivered dose was clinically effective, and no further treatment is planned. No adverse patient impacts are expected.
"The discovery was made during a quarterly review of their written directive on March 20, 2024.
"The Agency is awaiting further information from the licensee."
* * * UPDATE ON 4/25/24 AT 1045 EDT FROM SUSAN ELLIOTT TO BILL GOTT * * *
The following information was provided by the Arkansas Department of Health, Radiation Control Radioactive Material Program (the Agency) via email:
"The discovery was made during a quarterly review of their written directive on March 12, 2024 (Corrected date).
"The authorized user prescribed an activity of 2.6 GBq (70 mCi) on February 7, 2024. The technologist drew up 3.17 GBq (85.8 mCi) which was 122 percent of the prescribed activity and delivered the syringe to the authorized user. The authorized user performed the administration within 30 minutes of the dose being drawn. The administered activity was estimated to be 84.5 mCi, 120 percent of the prescribed activity.
"The authorized user contacted the patient's referring physician and both were satisfied with the activity delivered as the goal was to ablate the entire segment of diseased liver. The absorbed doses to all other tissues were below the targets for treatment with Y90.
"Personnel interviews were conducted by the department on April 2, 2024, aimed at gaining insight into the incident and engaging in discussions regarding the procedures involved.
"The event is considered closed."
Notified R4DO (Warnick) and NMSS Events Notification (email)
Arkansas Event #: AR-2024-2
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.
EN Revision Text: AGREEMENT STATE REPORT - Y-90 MICROSPHERE MISADMINISTRATION
The following information was provided by the Arkansas Department of Health, Radiation Control Radioactive Material Program (the Agency) via email:
"The radiation safety officer for Central Arkansas Radiation Therapy Institute (CARTI) contacted the Agency on March 21, 2024, to advise of a yttrium-90 (Y-90) microsphere therapy administration in which the patient received 20 percent greater than the prescribed dose. The administration occurred on February 7, 2024. Treatment was only to one side of the liver. The amount was localized to the liver. The physician felt the delivered dose was clinically effective, and no further treatment is planned. No adverse patient impacts are expected.
"The discovery was made during a quarterly review of their written directive on March 20, 2024.
"The Agency is awaiting further information from the licensee."
* * * UPDATE ON 4/25/24 AT 1045 EDT FROM SUSAN ELLIOTT TO BILL GOTT * * *
The following information was provided by the Arkansas Department of Health, Radiation Control Radioactive Material Program (the Agency) via email:
"The discovery was made during a quarterly review of their written directive on March 12, 2024 (Corrected date).
"The authorized user prescribed an activity of 2.6 GBq (70 mCi) on February 7, 2024. The technologist drew up 3.17 GBq (85.8 mCi) which was 122 percent of the prescribed activity and delivered the syringe to the authorized user. The authorized user performed the administration within 30 minutes of the dose being drawn. The administered activity was estimated to be 84.5 mCi, 120 percent of the prescribed activity.
"The authorized user contacted the patient's referring physician and both were satisfied with the activity delivered as the goal was to ablate the entire segment of diseased liver. The absorbed doses to all other tissues were below the targets for treatment with Y90.
"Personnel interviews were conducted by the department on April 2, 2024, aimed at gaining insight into the incident and engaging in discussions regarding the procedures involved.
"The event is considered closed."
Notified R4DO (Warnick) and NMSS Events Notification (email)
Arkansas Event #: AR-2024-2
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.