Event Notification Report for June 09, 2025

AGREEMENT STATE REPORT - MEDICAL EVENT

The following is a summary of information provided by the North Carolina Department of Health and Human Services Radioactive Materials Branch (RMB) via email:

The licensee reported to RMB that around 1500 EDT on 05/29/25, a routine Pluvicto infusion (the second of six planned) presented challenges with gravity delivery of the dose. Staff experienced difficulty initiating forward flow from the saline line into the vial. Attempts to correct the condition were unsuccessful and the procedure was discontinued.

The patient was prescribed to receive 200 mCi of Lu-177 to the prostate but it was calculated the patient only received 117.1 mCi. Post-treatment surveys of the patient were completed; the highest survey reading at one meter was 1.01 mr/hr. Contamination surveys were completed directly after infusion and minimal contamination was found around vial. The tubing, peripheral intravenous (PIV) extensions, and vial were all secured and assayed by radiation safety specialist. Staff moved all waste to disposal and all subsequent area survey readings were at background. The infusion room was cleared for general use. The unused dose was stored for disposal. Staff dosimetry has been sent for processing, but no elevated readings are expected.

The patient was immediately notified of the event and was released. The licensee does not expect the patient's treatment plan to alter due to this event. The medical director also reached out to the patient and referring physician later that day to discuss the event.

After discussions with the radiation safety officer and review of available staff reports, [RMB determined that] the licensee did follow the manufacturer's procedure.

RMB's investigation is ongoing.

NC Event Number: NC250007

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.

INVALID SPECIFIED SYSTEM ACTUATION

The following information was provided by the licensee via phone and email:

"At 2315 EDT on April 11, 2025, the spare train of Unit 2 auxiliary feedwater (AFW), the turbine-driven AFW pump (TDAFWP), automatically started. At the time, Unit 2 was entering a refueling outage and had been shutdown to hot standby conditions. Sufficient makeup water to the steam generators was being supplied by the 'A' and 'B' trains of AFW, [both] motor-driven AFW pumps. Several hours before this automatic start, feed from all main feedwater pumps (MFWPs) and the TDAFWP had been secured.

"The TDAFWP automatically started during the alignment of Unit 2 balance-of-plant to support the outage. As part of the alignment, condenser vacuum for the '2A' MFWP was broken prior to the de-energization of the '2A' MFWP's turbine trip bus. Even though the '2A' MFWP was incapable of providing any main feedwater flow, the order in which these two events were performed appeared to the protective circuitry as a low-vacuum trip of the '2A' MWFP, and thus a loss of all MFWPs. The loss of all MFWPs is an automatic start signal to the TDAFWP.

"This report is being made under 10 CFR 50.73(a)(2)(iv)(A) as an event that resulted in an invalid actuation of the Unit 2 TDAFWP.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector was notified of the event."