United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for April 4, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/01/2005 - 04/04/2005

** EVENT NUMBERS **


41532 41542 41558

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Hospital Event Number: 41532
Rep Org: ST JOSEPH REGIONAL MEDICAL CENTER
Licensee: ST JOSEPH REGIONAL MEDICAL CENTER
Region: 3
City: SOUTH BEND State: IN
County:
License #: 13-02650-02
Agreement: N
Docket:
NRC Notified By: JOHN SCHEU
HQ OPS Officer: BILL GOTT
Notification Date: 03/28/2005
Notification Time: 11:13 [ET]
Event Date: 02/23/2004
Event Time: [CST]
Last Update Date: 04/01/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
KENNETH RIEMER (R3)
TOM ESSIG (NMSS)

Event Text

MEDICAL EVENT

The following information was supplied by the licensee:

"Two patients involved in what we now think to be reportable events.
1. A.M. 2-23-04 to 2-24-04
2. R.M. 3-01-04 to 3-02-04

"In both cases the patients were being treated for endometrial cancer with brachytherapy. A new Wang vaginal applicator was used. The tandem was loaded with incorrect size sources (of Cs-137) which then had the ability to slide out of the intended treatment position through the placement spring when the patient would sit in a more up-right position. With the sources out of position they would irradiate the patients inner thigh. The dose to the thigh had to be estimated based on estimated time the patient was in an up-right position and the effect seen on the skin.

"At the time these incidents took place it was not felt that reportable events had taken place because of the calculated exposure to the thigh, patient symptoms, and the interpretation of 35.3045 (a) (1)(2), (3).

"One of the patients (A.M.) returned recently (1/05) with an ulcer at the area of thigh exposure. This has caused the radiation therapy staff to reevaluate their dose estimation to the patients. After review, it is believed that reportable events my have occurred based on 35.3045 (A) (3).

"This conclusion was formulated on 3-25-05 after a staff meeting and 1 received the final letter from the physician today 3-28-05."


The tandem manufacturer recommends 3M seeds and the facility used Amersham seeds which resulted in the seeds shifting. A total of 5 patients were treated. The initial estimates determined that the exposure was less than the reportable limit. All the patients were notified of the exposure.

One of the two overexposed patients is responding well to treatment. The other patient may have received the higher dose. The remaining three patients appear to have received less than the reportable dose.

* * * UPDATE FROM JOHN SCHEU TO JEFF ROTTON ON 4/1/2005 AT 1608 * * *

Discussion between the licensee and NRC Region 3 inspectors determined that a third patient should be added to this event:
3. K.B. 3-19-04 to 3-22-04

Notified R3DO (Riemer) and NMSSEO (Collins).

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General Information or Other Event Number: 41542
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: LOWELL GENERAL HOSPITAL
Region: 1
City: LOWELL State: MA
County:
License #: 44-0060
Agreement: Y
Docket: 02-5396
NRC Notified By: TONY CARPENITO
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/29/2005
Notification Time: 12:46 [ET]
Event Date: 01/17/2005
Event Time: 12:00 [EST]
Last Update Date: 03/29/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1)
TOM ESSIG (NMSS)

Event Text

MEDICAL MISADMINISTRATION - WRONG TREATMENT SITE

The State provided the following NMED information:

"On 1/18/05, the licensee reported to the Agency a teletherapy misadministration that occurred on 1/17/05. The situation was described as 'the treatment field was displaced by six cm when the therapist set the central axis of the field at the tattoo marking the bottom of the field'. An area of 15 cm x 6 cm (treatment site) received dose when the plan called for that tissue to receive no dose. The dose was one day's treatment of 180 cGy. The treatment monitor units and energy were correct, the error was entirely an issue of field placement."

The Regulation Code cited is 105 CFR 120.502 (4) (a). The intended dose to the patient was 180 cGy, however, only 90 cGy was given to the wrong treatment site (15 cm x 6 cm area). Per the treating physician, no corrective action is needed. The hospital retrained staff to ensure confirming proper positioning of therapy prior to treatment.

"Event type Description: MD2 - Wrong Treatment Site.

"Cause description: The therapist did not correctly align the treatment field with the patient's treatment alignment tattoo."

"The Agency considers this event closed."

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Power Reactor Event Number: 41558
Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: KEVIN McLAUGHLIN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/01/2005
Notification Time: 16:30 [ET]
Event Date: 04/01/2005
Event Time: 14:02 [EST]
Last Update Date: 04/01/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JAMES TRAPP (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

EMERGENCY DIESEL GENERATOR START DUE TO A PARTIAL LOSS OF OFFSITE POWER

The following information was provided by the licensee via fax (licensee text in quotes):


"With the plant in mode 6 and refueling operations in progress, a loss of offsite power circuit 751 occurred. This loss of power caused an undervoltage condition on safeguards busses 16 and 17 and an automatic start of Emergency Diesel Generator 1B. Both of these busses were subsequently energized by the diesel. Refueling operations in progress were immediately halted. Core cooling was momentarily interrupted and restored upon safeguards bus reenergization. The spent fuel pool cooling loop in operation was powered from the opposite train and hence was not interrupted. RCS temperature was maintained at 74 degrees Fahrenheit and spent fuel pool temperature was also at 74 degrees Fahrenheit throughout the event."

This partial loss of power was due to a substation transformer fault (one of two offsite power sources were lost).

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012