Event Notification Report for March 12, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/11/2025 - 03/12/2025
Agreement State
Event Number: 57617
Rep Org: Minnesota Department of Health
Licensee: IRISNDT, Inc.
Region: 3
City: St. Paul Park State: MN
County:
License #: 1238
Agreement: Y
Docket:
NRC Notified By: Tyler Kruse
HQ OPS Officer: Ernest West
Licensee: IRISNDT, Inc.
Region: 3
City: St. Paul Park State: MN
County:
License #: 1238
Agreement: Y
Docket:
NRC Notified By: Tyler Kruse
HQ OPS Officer: Ernest West
Notification Date: 03/19/2025
Notification Time: 11:31 [ET]
Event Date: 03/13/2025
Event Time: 00:00 [CDT]
Last Update Date: 03/19/2025
Notification Time: 11:31 [ET]
Event Date: 03/13/2025
Event Time: 00:00 [CDT]
Last Update Date: 03/19/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Havertape, Joshua (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Havertape, Joshua (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - UNABLE TO RETRACT SOURCE
The following information was received from the Minnesota Department of Health (MDH), Radioactive Materials Unit via email:
"On March 13, 2025, during a radiography exposure, the radiography crew noted that too much drive cable extended into the guide tube. The radiographer cranked in to investigate and was unable to return the source to the exposure device. The radiation safety officer (RSO) was notified, and the crew began expanding their boundaries. The RSO initiated source retrieval operations. After shielding the source with lead shot, and performing some tests, it was determined that the source had not disconnected and that the guide tube was not attached to the camera. The RSO then `jiggled the drive cable' and was able to crank the source back into the shielded position. The RSO estimates that the source was exposed for less than 1 hour.
"After investigation, the RSO determined that the guide tube was never properly secured to the quick connect at the end of the exposure device. Cranking the source out to the end of the guide tube disconnected the guide tube from the exposure device. When retracting the source, the source pigtail caught on the quick connect port on the end of the exposure device due to the weight of the guide tube on the drive cable. To determine if the source was still connected, the RSO pulled on the controls and thus the drive cable and pig tail were pulled out of the guide tube. With the weight of the guide tube now off of the drive cable, the RSO was able to jiggle the controls and dislodge the pigtail from the quick connect at the end of the exposure device and retract the source completely.
"MDH was notified of the event on March 18, 2025, at approximately 1350 [CDT]. MDH is considering enforcement action due to the late notification of the event. An on-site investigation is planned for March 20, 2025.
"The device is a Source Production and Equipment Company (SPEC) model 150 radiography camera."
Minnesota Event Report ID: MN250002
The following information was received from the Minnesota Department of Health (MDH), Radioactive Materials Unit via email:
"On March 13, 2025, during a radiography exposure, the radiography crew noted that too much drive cable extended into the guide tube. The radiographer cranked in to investigate and was unable to return the source to the exposure device. The radiation safety officer (RSO) was notified, and the crew began expanding their boundaries. The RSO initiated source retrieval operations. After shielding the source with lead shot, and performing some tests, it was determined that the source had not disconnected and that the guide tube was not attached to the camera. The RSO then `jiggled the drive cable' and was able to crank the source back into the shielded position. The RSO estimates that the source was exposed for less than 1 hour.
"After investigation, the RSO determined that the guide tube was never properly secured to the quick connect at the end of the exposure device. Cranking the source out to the end of the guide tube disconnected the guide tube from the exposure device. When retracting the source, the source pigtail caught on the quick connect port on the end of the exposure device due to the weight of the guide tube on the drive cable. To determine if the source was still connected, the RSO pulled on the controls and thus the drive cable and pig tail were pulled out of the guide tube. With the weight of the guide tube now off of the drive cable, the RSO was able to jiggle the controls and dislodge the pigtail from the quick connect at the end of the exposure device and retract the source completely.
"MDH was notified of the event on March 18, 2025, at approximately 1350 [CDT]. MDH is considering enforcement action due to the late notification of the event. An on-site investigation is planned for March 20, 2025.
"The device is a Source Production and Equipment Company (SPEC) model 150 radiography camera."
Minnesota Event Report ID: MN250002
Power Reactor
Event Number: 57604
Facility: Turkey Point
Region: 2 State: FL
Unit: [4] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: Dan Bittner
HQ OPS Officer: Jordan Wingate
Region: 2 State: FL
Unit: [4] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: Dan Bittner
HQ OPS Officer: Jordan Wingate
Notification Date: 03/14/2025
Notification Time: 00:18 [ET]
Event Date: 03/13/2025
Event Time: 18:47 [EDT]
Last Update Date: 03/14/2025
Notification Time: 00:18 [ET]
Event Date: 03/13/2025
Event Time: 18:47 [EDT]
Last Update Date: 03/14/2025
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Pearson, Laura (R2DO)
Pearson, Laura (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 4 | N | N | 0 | Refueling | 0 | Refueling |
AUTOMATIC ACTUATION OF '4B' EMERGENCY DIESEL GENERATOR
The following information was provided by the licensee via phone and email:
"At 1847 EDT on 3/13/25, with Unit 4 in mode 6 and defueled, an actuation of the 4B emergency diesel generator (EDG) occurred when the Unit 4 startup transformer '4B' 4kV Bus Supply Breaker '4AB05' tripped open. The '4B' EDG automatically started and energized the '4B' 4kV Bus as designed when the undervoltage condition caused the '4B' sequencer loss of offsite power signal to be received.
"This event is being reported pursuant to 10 CFR 50.72(b)(3)(iv)(A).
"The NRC Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
All systems responded as expected for the loss of voltage. There was no impact to the health and safety of the public or plant personnel. The cause of the breaker opening is under investigation. Power remains available to the '4B' 4kV Bus via both the '4B' EDG and the station blackout tie bus.
The following information was provided by the licensee via phone and email:
"At 1847 EDT on 3/13/25, with Unit 4 in mode 6 and defueled, an actuation of the 4B emergency diesel generator (EDG) occurred when the Unit 4 startup transformer '4B' 4kV Bus Supply Breaker '4AB05' tripped open. The '4B' EDG automatically started and energized the '4B' 4kV Bus as designed when the undervoltage condition caused the '4B' sequencer loss of offsite power signal to be received.
"This event is being reported pursuant to 10 CFR 50.72(b)(3)(iv)(A).
"The NRC Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
All systems responded as expected for the loss of voltage. There was no impact to the health and safety of the public or plant personnel. The cause of the breaker opening is under investigation. Power remains available to the '4B' 4kV Bus via both the '4B' EDG and the station blackout tie bus.
Power Reactor
Event Number: 57605
Facility: Vogtle 3/4
Region: 2 State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: Sarah Gillham
HQ OPS Officer: Tenisha Meadows
Region: 2 State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: Sarah Gillham
HQ OPS Officer: Tenisha Meadows
Notification Date: 03/14/2025
Notification Time: 07:58 [ET]
Event Date: 03/13/2025
Event Time: 11:57 [EDT]
Last Update Date: 03/14/2025
Notification Time: 07:58 [ET]
Event Date: 03/13/2025
Event Time: 11:57 [EDT]
Last Update Date: 03/14/2025
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Pearson, Laura (R2DO)
FFD Group, (EMAIL)
Pearson, Laura (R2DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 4 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS FOR DUTY
The following information was provided by the licensee via phone and email:
A licensed employee had a confirmed positive test for alcohol during a test specified by the FFD testing program. The employee's access to the site has been terminated.
The NRC Resident Inspector has been notified.
The following information was provided by the licensee via phone and email:
A licensed employee had a confirmed positive test for alcohol during a test specified by the FFD testing program. The employee's access to the site has been terminated.
The NRC Resident Inspector has been notified.
Power Reactor
Event Number: 57606
Facility: LaSalle
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: Matthew Tutich
HQ OPS Officer: Jordan Wingate
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: Matthew Tutich
HQ OPS Officer: Jordan Wingate
Notification Date: 03/14/2025
Notification Time: 11:48 [ET]
Event Date: 03/13/2025
Event Time: 13:00 [CDT]
Last Update Date: 03/14/2025
Notification Time: 11:48 [ET]
Event Date: 03/13/2025
Event Time: 13:00 [CDT]
Last Update Date: 03/14/2025
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Edwards, Rhex (R3DO)
FFD Group, (EMAIL)
Edwards, Rhex (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
The following information was provided by the licensee via phone and email:
A licensed employee violated the FFD policy. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
The following information was provided by the licensee via phone and email:
A licensed employee violated the FFD policy. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
Power Reactor
Event Number: 57603
Facility: Turkey Point
Region: 2 State: FL
Unit: [4] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: Steve Murano
HQ OPS Officer: Robert A. Thompson
Region: 2 State: FL
Unit: [4] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: Steve Murano
HQ OPS Officer: Robert A. Thompson
Notification Date: 03/13/2025
Notification Time: 19:40 [ET]
Event Date: 03/13/2025
Event Time: 19:02 [EDT]
Last Update Date: 03/14/2025
Notification Time: 19:40 [ET]
Event Date: 03/13/2025
Event Time: 19:02 [EDT]
Last Update Date: 03/14/2025
Emergency Class: Unusual Event
10 CFR Section:
50.72(a) (1) (i) - Emergency Declared
10 CFR Section:
50.72(a) (1) (i) - Emergency Declared
Person (Organization):
Pearson, Laura (R2DO)
Mark Miller (R2RA)
Greg Bowman (NRR)
Crouch, Howard (IR)
Dave Gasperson (R2 PAO)
Pearson, Laura (R2DO)
Mark Miller (R2RA)
Greg Bowman (NRR)
Crouch, Howard (IR)
Dave Gasperson (R2 PAO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 4 | N | N | 0 | Defueled | 0 | Defueled |
EN Revision Imported Date: 3/17/2025
EN Revision Text: UNUSUAL EVENT - LOSS OF OFFSITE POWER
The following information was provided by the licensee via phone and email:
"At 1902 EDT on 3/13/2025 Turkey Point Nuclear Plant Unit 4 declared an Unusual Event due to a loss of offsite power [to the '4B' 4KV bus]. The '4B' 4KV bus was re-energized from the '4B' emergency diesel generator (EDG). The '4A' 4KV bus is de-energized as part of the pre-planned outage scope. The cause of the loss of Unit 4 startup transformer is not known at this time. All plant parameters are stable."
State and local agencies were notified. The NRC resident inspector has been notified.
Notified DHS SWO, FEMA Operations Center, CISA Central Watch Officer, FEMA NWC, DHS Nuclear SSA (email), CWMD Watch Desk (email).
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The licensee is evaluating the startup transformer before transferring the '4B' 4KV bus back to offsite power. Spent fuel pool cooling remained in-service as it was powered from Unit 3. Unit 3 was unaffected and remains at 100 percent power.
* * * UPDATE ON 03/13/2025 AT 2318 EDT FROM DANIEL BITTNER TO KERBY SCALES * * *
"At 2056 EDT on 3/13/2025, Turkey Point Nuclear Station Unit 4 terminated the Unusual Event due to a loss of offsite power. The event was terminated due to more than one emergency power source being available; `4B' emergency diesel generator and `4D' bus station blackout tie."
Notified R2DO (Pearson), DHS SWO, FEMA Operations Center, CISA Central Watch Officer, FEMA NWC, DHS Nuclear SSA (email), CWMD Watch Desk (email).
* * * RETRACTION ON 03/14/2025 AT 0518 EDT FROM DANIEL BITTNER TO JORDAN WINGATE * * *
"Turkey Point Nuclear Station Unit 4 is retracting this notification based on additional information not immediately identified at the time of notification. Following the loss of the '4B' 4kV bus event on 3/13/25, the emergency action level (EAL) technical bases document for CU2.1 was reviewed and identified that more than one emergency power source was still available at the time of the event and could have been credited. Specifically, the '4B' EDG and the '4D' bus station blackout cross tie (powered by Unit 3) emergency power sources were still available. The initial report was based on the available information at the time pursuant to emergency declaration and reporting notification requirements.
"The NRC Resident has been notified."
Notified R2DO (Pearson), Region 2 RA (Miller), NRR (Bowman). IR MOC (Crouch), Region 2 PAO (Gasperson), NRR EO (Felts), and NSIR (Erlanger)
EN Revision Text: UNUSUAL EVENT - LOSS OF OFFSITE POWER
The following information was provided by the licensee via phone and email:
"At 1902 EDT on 3/13/2025 Turkey Point Nuclear Plant Unit 4 declared an Unusual Event due to a loss of offsite power [to the '4B' 4KV bus]. The '4B' 4KV bus was re-energized from the '4B' emergency diesel generator (EDG). The '4A' 4KV bus is de-energized as part of the pre-planned outage scope. The cause of the loss of Unit 4 startup transformer is not known at this time. All plant parameters are stable."
State and local agencies were notified. The NRC resident inspector has been notified.
Notified DHS SWO, FEMA Operations Center, CISA Central Watch Officer, FEMA NWC, DHS Nuclear SSA (email), CWMD Watch Desk (email).
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The licensee is evaluating the startup transformer before transferring the '4B' 4KV bus back to offsite power. Spent fuel pool cooling remained in-service as it was powered from Unit 3. Unit 3 was unaffected and remains at 100 percent power.
* * * UPDATE ON 03/13/2025 AT 2318 EDT FROM DANIEL BITTNER TO KERBY SCALES * * *
"At 2056 EDT on 3/13/2025, Turkey Point Nuclear Station Unit 4 terminated the Unusual Event due to a loss of offsite power. The event was terminated due to more than one emergency power source being available; `4B' emergency diesel generator and `4D' bus station blackout tie."
Notified R2DO (Pearson), DHS SWO, FEMA Operations Center, CISA Central Watch Officer, FEMA NWC, DHS Nuclear SSA (email), CWMD Watch Desk (email).
* * * RETRACTION ON 03/14/2025 AT 0518 EDT FROM DANIEL BITTNER TO JORDAN WINGATE * * *
"Turkey Point Nuclear Station Unit 4 is retracting this notification based on additional information not immediately identified at the time of notification. Following the loss of the '4B' 4kV bus event on 3/13/25, the emergency action level (EAL) technical bases document for CU2.1 was reviewed and identified that more than one emergency power source was still available at the time of the event and could have been credited. Specifically, the '4B' EDG and the '4D' bus station blackout cross tie (powered by Unit 3) emergency power sources were still available. The initial report was based on the available information at the time pursuant to emergency declaration and reporting notification requirements.
"The NRC Resident has been notified."
Notified R2DO (Pearson), Region 2 RA (Miller), NRR (Bowman). IR MOC (Crouch), Region 2 PAO (Gasperson), NRR EO (Felts), and NSIR (Erlanger)
Power Reactor
Event Number: 57600
Facility: McGuire
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Daniel Peeler
HQ OPS Officer: Kerby Scales
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Daniel Peeler
HQ OPS Officer: Kerby Scales
Notification Date: 03/12/2025
Notification Time: 17:03 [ET]
Event Date: 03/12/2025
Event Time: 12:00 [EDT]
Last Update Date: 03/12/2025
Notification Time: 17:03 [ET]
Event Date: 03/12/2025
Event Time: 12:00 [EDT]
Last Update Date: 03/12/2025
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Suber, Gregory (R2DO)
FFD Group, (EMAIL)
Suber, Gregory (R2DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 95 | Power Operation | 95 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 3/18/2025
EN Revision Text: FITNESS FOR DUTY
The following information was provided by the licensee via phone and email:
A non-licensed contract supervisor had a confirmed positive for illegal drugs during a fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
EN Revision Text: FITNESS FOR DUTY
The following information was provided by the licensee via phone and email:
A non-licensed contract supervisor had a confirmed positive for illegal drugs during a fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
Agreement State
Event Number: 57624
Rep Org: Georgia Radioactive Material Pgm
Licensee: Dekalb Med Ctr/Emory Decatur Hosp
Region: 1
City: Lithonia State: GA
County:
License #: GA 206-1
Agreement: Y
Docket:
NRC Notified By: Anastasia Bennett
HQ OPS Officer: Jordan Wingate
Licensee: Dekalb Med Ctr/Emory Decatur Hosp
Region: 1
City: Lithonia State: GA
County:
License #: GA 206-1
Agreement: Y
Docket:
NRC Notified By: Anastasia Bennett
HQ OPS Officer: Jordan Wingate
Notification Date: 03/25/2025
Notification Time: 16:10 [ET]
Event Date: 03/12/2025
Event Time: 00:00 [EDT]
Last Update Date: 04/03/2025
Notification Time: 16:10 [ET]
Event Date: 03/12/2025
Event Time: 00:00 [EDT]
Last Update Date: 04/03/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Arner, Frank (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Silberfeld, Dafna (NMSS)
Arner, Frank (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Silberfeld, Dafna (NMSS)
EN Revision Imported Date: 4/4/2025
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by the Georgia Radioactive Materials Program via email:
"Licensee contact stated the following: On March 12, 2025, a 71-year-old female patient received an administration of 1.98 millicuries (mCi) of sodium iodide I-123 for nuclear medicine thyroid imaging with uptake. The standard prescribed dose for this study is approximately 200 microcuries. Initial dose calculations, based on the package insert and a measured thyroid uptake of 64.7 percent, estimate the absorbed thyroid dose to be 1.67 Gy (167 rad). These calculations assume administration occurred near the end of the drug's expiration period. Further clarification regarding the exact dosing time will assist in refining the thyroid dose assessment.
"An investigation is ongoing to determine the source of this dosing discrepancy. A formal written report will be submitted by the licensee on Friday, March 28, 2025."
GA NMED Report Incident #92
* * * UPDATE ON 03/31/2025 AT 1551 EDT FROM ANASTASIA BENNETT TO KERBY SCALES * * *
The following update is a summary of information received from the Georgia Radioactive Materials Program via email:
A patient was supposed to receive 200 microcuries of iodine-123 but instead received 1.98 mCi for a thyroid imaging study. The administered dose was approximately ten times higher than intended. This error resulted from miscommunication and mislabeling of the dose. The authorized user assessed the situation and determined that the risk of thyroid harm was minimal. The hospital calculated the thyroid dose to be approximately 1.74 Gy (174 rad) and has since implemented new safety measures. These include requiring faxed orders for radiopharmaceuticals and instituting multiple reviews for dose inspections to prevent future errors.
Notified R1DO (Bickett), NMSS Coordinator (Allen), NMSS (Silberfeld) and NMSS Events_Notification (email).
* * * UPDATE ON 04/03/2025 AT 1033 EDT FROM ANASTASIA BENNETT TO JORDAN WINGATE * * *
The following update is a summary of information received from the Georgia Radioactive Materials Program via email:
On April 2, 2025, a phone call was made to the radiation safety officer (RSO) for further clarification. The error originated from an incorrect recording of the dose units by the nuclear technician. The misrecorded information was then relayed to RLS Radiopharmacies, resulting in a labeling discrepancy. The technician did not verify or cross-check the recorded units before confirming the prescribed dose. The licensee is working to acquire an electronic tracking system like Epic within the next two months to ensure that miscommunications are limited. The radiation safety officer submitted a follow-up email to provide further clarification.
Notified R1DO (Bickett), NMSS Coordinator (Allen), NMSS (Silberfeld) and NMSS Events_Notification (email).
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 - MEDICAL EVENT
The following information was provided by the Georgia Radioactive Materials Program via email:
"Licensee contact stated the following: On March 12, 2025, a 71-year-old female patient received an administration of 1.98 millicuries (mCi) of sodium iodide I-123 for nuclear medicine thyroid imaging with uptake. The standard prescribed dose for this study is approximately 200 microcuries. Initial dose calculations, based on the package insert and a measured thyroid uptake of 64.7 percent, estimate the absorbed thyroid dose to be 1.67 Gy (167 rad). These calculations assume administration occurred near the end of the drug's expiration period. Further clarification regarding the exact dosing time will assist in refining the thyroid dose assessment.
"An investigation is ongoing to determine the source of this dosing discrepancy. A formal written report will be submitted by the licensee on Friday, March 28, 2025."
GA NMED Report Incident #92
* * * UPDATE ON 03/31/2025 AT 1551 EDT FROM ANASTASIA BENNETT TO KERBY SCALES * * *
The following update is a summary of information received from the Georgia Radioactive Materials Program via email:
A patient was supposed to receive 200 microcuries of iodine-123 but instead received 1.98 mCi for a thyroid imaging study. The administered dose was approximately ten times higher than intended. This error resulted from miscommunication and mislabeling of the dose. The authorized user assessed the situation and determined that the risk of thyroid harm was minimal. The hospital calculated the thyroid dose to be approximately 1.74 Gy (174 rad) and has since implemented new safety measures. These include requiring faxed orders for radiopharmaceuticals and instituting multiple reviews for dose inspections to prevent future errors.
Notified R1DO (Bickett), NMSS Coordinator (Allen), NMSS (Silberfeld) and NMSS Events_Notification (email).
* * * UPDATE ON 04/03/2025 AT 1033 EDT FROM ANASTASIA BENNETT TO JORDAN WINGATE * * *
The following update is a summary of information received from the Georgia Radioactive Materials Program via email:
On April 2, 2025, a phone call was made to the radiation safety officer (RSO) for further clarification. The error originated from an incorrect recording of the dose units by the nuclear technician. The misrecorded information was then relayed to RLS Radiopharmacies, resulting in a labeling discrepancy. The technician did not verify or cross-check the recorded units before confirming the prescribed dose. The licensee is working to acquire an electronic tracking system like Epic within the next two months to ensure that miscommunications are limited. The radiation safety officer submitted a follow-up email to provide further clarification.
Notified R1DO (Bickett), NMSS Coordinator (Allen), NMSS (Silberfeld) and NMSS Events_Notification (email).
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.