Event Notification Report for February 04, 2021

AGREEMENT STATE REPORT - INCORRECT DOSE DELIVERED TO PATIENT

The following information was received from the state of California via email:

"On January 25, 2021, the Radiation Safety Officers [RSO] discovered and reported to CDPH [California Department of Public Health] that a medical event had occurred on December 28, 2020. The RSO stated that during a routine review of the past month's radiation therapies, they discovered that a Y-90 Nordion TheraSphere treatment performed on 12/28/2020 resulted in a delivered dose that was approximately 33 percent greater than the physician's written directive (550 Gy) signed on 12/15/2020. This higher patient dose was the result of administering the dose on Monday (12/28/2020) that was calibrated for administration on Tuesday (12/29/2020). The licensee will be submitting their 15 day report per 10 CFR 35.3045."

California report no.: 012521

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.

ALERT DECLARED DUE TO RADIOACTIVE RELEASE TO THE ENVIRONMENT

At 0910 EST, the National Institute of Standards and Technology (NIST) Center for Neutron Research (NCNR) test reactor declared an ALERT in accordance with their NRC approved Emergency Plan, due to the stack radiation monitor reading 100,000 counts per minute due to the release of fission products. The reactor had been operating at 50% power (10 MW), and automatically scrammed one minute prior based on the stack monitor reaching 50,000 counts per minute. When the automatic scram occurred, the facility ventilation system automatically changed to emergency ventilation mode to limit discharge to the environment. Several workers were determined to be externally contaminated and these workers were decontaminated by a change of clothes and showers. These workers are being monitored for possible uptake of internal contamination. Environmental surveys are in progress.

The NRC remained in the normal mode.

Notified DHS SWO, FEMA Operations Center, CISA Central, USDA Operations Center, HHS Operations Center, DOE Operations Center, EPA Emergency Operations Center, FDA EOC (email), FEMA NWC (email), FEMA NRCC SASC (email) and NuclearSSA (email).

* * * UPDATE FROM TOM NEWTON TO KARL DIEDERICH AT 1532 EST ON 2/3/21 * * *

Event is downgraded to a Notification of Unusual Event (NOUE) based upon environmental samples at the site boundary. Members of the public are not expected to have been contaminated.

Notified R1DO (Dentel), NRR EO (Miller), IRD (Kennedy), DHS SWO, FEMA Operations Center, CISA Central, USDA Operations Center, HHS Operations Center, DOE Operations Center, EPA Emergency Operations Center, FDA EOC (email), FEMA NWC (email), FEMA NRCC SASC (email) and NuclearSSA (email).

* * * UPDATE FROM TOM NEWTON TO HOWIE CROUCH AT 1940 EST ON 2/3/21 * * *

At 1935 EST, NIST terminated the Notification of Unusual Event. The basis for termination was that all air samples were normal.

Notified R1DO (Dentel), NRR EO (Miller), IRD (Kennedy), NPR PM (Torres and Montgomery), NPR (Takacs), DHS SWO, FEMA Operations Center, CISA Central, USDA Operations Center, HHS Operations Center, DOE Operations Center, EPA Emergency Operations Center, FDA EOC (email), FEMA NWC (email), FEMA NRCC SASC (email) and NuclearSSA (email).