| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
03/29/2007 - 03/30/2007 ** EVENT NUMBERS ** |
 | !!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!! | | Hospital | Event Number: 43256 | Rep Org: LANCASTER GENERAL HOSPITAL
Licensee: LANCASTER GENERAL HOSPITAL
Region: 1
City: LANCASTER State: PA
County:
License #: 37-1186-01
Agreement: N
Docket:
NRC Notified By: ANTHONY MONTAGENESE
HQ OPS Officer: STEVE SANDIN | Notification Date: 03/23/2007
Notification Time: 19:30 [ET]
Event Date: 03/23/2007
Event Time: 13:00 [EDT]
Last Update Date: 03/28/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
| Person (Organization):
MEL GRAY (R1)
E. WILLIAM BRACH (FSME)
| Event Text POTENTIAL OVEREXPOSURE INVOLVING BRACHYTHERAPY SOURCE
At 1300 hours on 3/23/07, a male patient received I-125 seed implants for treatment of prostate cancer. The RSO received a call at approximately 1730 hours from the Radiation Oncologist Physicist who had identified that the wrong units were input into the dose planning computer. This resulted in a potential overexposure. A CAT scan is scheduled for Monday, 3/26/07, to verify source placement and more accurately calculate the overexposure. At this time, the preliminary information provided indicates a prescribed dose of 145 Gray with an estimated dose delivery of 155 Gray. The licensee does not believe that there will be any adverse effects to the patient. Following the more accurate calculation the licensee will review whether this notification meets the reporting criteria.
The licensee has notified the prescribing physician of the error.
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.
* * * UPDATE ON 3/28/07 AT 1417 FROM MONTAGENESE TO SNYDER * * *
This event is retracted by the licensee. Since the time of the original notification the licensee has established, by dosimetry readings, that the exposure was below the reporting criteria.
Notified R1DO (Dimitriadis) and FSME EO (Morell). |
| General Information or Other | Event Number: 43258 | Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CALIFORNIA SURGERY CENTER
Region: 4
City: Bakersfield State: CA
County:
License #: 6833-15
Agreement: Y
Docket:
NRC Notified By: BARBARA HAMRICK
HQ OPS Officer: BILL HUFFMAN | Notification Date: 03/27/2007
Notification Time: 17:52 [ET]
Event Date: 03/19/2007
Event Time: [PDT]
Last Update Date: 03/27/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
JACK WHITTEN (R4)
LARRY CAMPER (FSME)
| Event Text AGREEMENT STATE - CALIFORNIA - MEDICAL MISADMINISTRATION
The State provided the following information via facsimile:
"On March 16, 2007, the licensee initiated a 'Mammosite' treatment of a patient, with a total prescribed dose of 3400 cGy (3400 rad) to be delivered in 10 fractions of 340 cGy (340 rad) each, over the course of 5 days, using a Nucletron, Model 105.999 HDRA with 4.1 Ci Ir-192 (as of the first day of treatment). The first five fractions were delivered uneventfully. During the last five fractions, the radiation therapy technologist accidentally imported the wrong treatment plan, resulting in an underdose to the treatment area. The dwell position of the source was actually fully outside of the patient, so the tumor received effectively no dose. The licensee is calculating the skin and whole body dose to the patient, but currently estimates it will not have an adverse affect upon the patient. The patient and referring physician have been notified, and re-treatment has been scheduled to begin tomorrow. This event was discovered upon review of the patient's chart when the patient returned for a follow-up exam. The licensee will provide a written report of the event within 15 days."
CA Report #032707
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. |
| Power Reactor | Event Number: 43264 | Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: ROBERT WHITE
HQ OPS Officer: JEFF ROTTON | Notification Date: 03/29/2007
Notification Time: 12:08 [ET]
Event Date: 03/29/2007
Event Time: 09:00 [EDT]
Last Update Date: 03/29/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
| Person (Organization):
ANTHONY DIMITRIADIS (R1)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 2 | N | Y | 100 | Power Operation | 100 | Power Operation | | 3 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text OFFSITE NOTIFICATION TO LOCAL LAW ENFORCEMENT
Licensee requested offsite assistance from local police department. Contact Headquarters Operations Officer for additional details.
The licensee notified the NRC Resident Inspector. | |