Event Notification Report for March 12, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/11/2025 - 03/12/2025
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.