U.S. Nuclear Regulatory Commission Operations Center Event Reports For 01/09/2008 - 01/10/2008 ** EVENT NUMBERS ** | Hospital | Event Number: 43882 | Rep Org: HACKLEY HOSPITAL Licensee: HACKLEY HOSPITAL Region: 3 City: MUSKEGON State: MI County: License #: 21-04125-01 Agreement: N Docket: NRC Notified By: CARLO SANTA ANNA HQ OPS Officer: JEFF ROTTON | Notification Date: 01/04/2008 Notification Time: 15:20 [ET] Event Date: 12/13/2007 Event Time: [EST] Last Update Date: 01/04/2008 | Emergency Class: NON EMERGENCY 10 CFR Section: 35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE | Person (Organization): PATRICK LOUDEN (R3) GREG MORELL (FSME) | Event Text PATIENT RECEIVED LESS THAT PRESCRIBED DOSE "On 12/13/07, a patient was scheduled for a thyroid ablation with 100 mCi of NaI-131. The dose arrived with 3 capsules totaling 95.5 mCi. The nuc med tech was unaware that the package contained 3 capsules due to lack of visualization. The nuc med tech administered 1 capsule with the activity of 21.39 mCi of NaI-131. The package was sent back to the pharmacy with the remaining 2 capsules of approximately 70 mCi of NaI-131. "The mistake was recognized the next morning. The radiologist was made aware of the situation and the patient notified immediately. The patient returned the morning of 12/14/07 and was administered the remaining 2 capsules totaling 69.7 mCi of NaI-131. "Overall, the patient received a total of 91.09 mCi of Nal-131 over the course of 17 hours." 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: 43887 | Facility: TURKEY POINT Region: 2 State: FL Unit: [3] [ ] [ ] RX Type: [3] W-3-LP,[4] W-3-LP NRC Notified By: EDDIE NEVILLE HQ OPS Officer: KARL DIEDERICH | Notification Date: 01/09/2008 Notification Time: 18:43 [ET] Event Date: 01/09/2008 Event Time: 16:30 [EST] Last Update Date: 01/09/2008 | Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE | Person (Organization): DAVID AYRES (R2) | Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | 3 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text ERDS FAILED TO DISCONNECT DURING TEST "Unit 3 was conducting a communication test of the Emergency Data Response System (ERDS). Following the test of the ERDS system, the ERDS modem would not disconnect with the NRC. The ERDS modem was disconnected in an effort to not overload the NRC communication system. The modem was disconnected at 16:30 EST on 1/9/2008. This constitutes a major loss of emergency assessment capability in accordance with 10 CFR 50.72 (b) (3) (xiii). The cause for the ERDS modem to auto-redial is not known. The ERDS link will be disconnected until the cause for the modem to auto-redial is determined and corrected. Follow-up NRC OC notification will be made when the ERDS link is re-established." The vendor is on site. The licensee has notified the resident inspector. *** UPDATED ON 1/9/08 AT 2122 EST BY EDDIE NEVILLE TO KARL DIEDERICH *** The ERDS modem has been repaired, tested satisfactorily, and returned to service. The licensee will notify the resident inspector. R2DO (Ayres) notified. | |