Event Notification Report for April 4, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
04/03/2002 - 04/04/2002
** EVENT NUMBERS **
38758 38790 38825 38826 38827 38828
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 38758 |
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| FACILITY: SUSQUEHANNA REGION: 1 |NOTIFICATION DATE: 03/09/2002|
| UNIT: [1] [] [] STATE: PA |NOTIFICATION TIME: 05:32[EST]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 03/09/2002|
+------------------------------------------------+EVENT TIME: 01:00[EST]|
| NRC NOTIFIED BY: GORDON ROBINSON |LAST UPDATE DATE: 04/03/2002|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MOHAMED SHANBAKY R1 |
|10 CFR SECTION: | |
|ADEG 50.72(b)(3)(ii)(A) DEGRADED CONDITION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Refueling |0 Refueling |
| | |
| | |
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EVENT TEXT
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| LOCAL LEAK RATE TEST FAILURE |
| |
| Appendix J Local Leak Rate Testing of Containment Penetration for Drywell |
| Sprays failed Tech Spec Acceptance Criteria for Secondary Containment Bypass |
| Leakage. The leakage limit is 9 standard cubic feet per hour and the test |
| results were 10.5 standard cubic feet per hour. The identified degraded |
| condition is reportable as a condition of the nuclear power plant, |
| including its principle safety barriers being seriously degraded per |
| 10CFR50.72(b)(3)(ii) |
| |
| The NRC Resident Inspector will be notified of this event by the licensee. |
| |
| ***UPDATE (RETRACTION) ON 4/3/02 at 1147 EST FROM ROBERT BOESCH TO RICH |
| LAURA*** |
| |
| "On 03/09/02, Appendix J Local Leak Rate Testing (LLRT) of a primary |
| containment penetration for Drywell Sprays failed Tech Spec Acceptance |
| Criteria for Secondary Containment Bypass Leakage. The test results were |
| attributed to the tested Containment Isolation Valve (CIV), HV151FO16A. The |
| identified condition was reported in EN#38758 as a Degraded Condition per 10 |
| CFR 50.72(b)(3)(ii)(A). |
| |
| "As a result of observations made during the testing, one of the test |
| boundary valves, HV151FO21A, was refurbished. Significant valve seat |
| degradation was noted after the test boundary valve was disassembled. After |
| the refurbishment of the test boundary valve, the Appendix J LLRT was |
| repeated for the tested CIV, HV151FOl 6A, with acceptable results. Since no |
| significant maintenance was performed on the tested CIV that would affect |
| its leak-tightness, the subsequent test results are valid for as-found |
| leakage of the tested CIV. The total As-Found Secondary Containment Bypass |
| Leakage was less than the Tech Spec limit. Based on this evaluation, ENS |
| Notification ENS38758 is retracted." |
| |
| The NRC Resident Inspector was notified. The R1DO (G. Meyer) was notified. |
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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 38790 |
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| FACILITY: LIMERICK REGION: 1 |NOTIFICATION DATE: 03/20/2002|
| UNIT: [1] [] [] STATE: PA |NOTIFICATION TIME: 22:56[EST]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 03/20/2002|
+------------------------------------------------+EVENT TIME: 15:43[EST]|
| NRC NOTIFIED BY: PETER A. GARDNER |LAST UPDATE DATE: 04/03/2002|
| HQ OPS OFFICER: GERRY WAIG +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |RICHARD CONTE R1 |
|10 CFR SECTION: | |
|AIND 50.72(b)(3)(v)(D) ACCIDENT MITIGATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 2 Startup |2 Startup |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| UNIT-1 HPCI SYSTEM FAILED TO MEET REQUIRED RESPONSE TIME DURING
SURVEILLANCE |
| TESTING |
| |
| "On 3/20/02 at 15:43 the Unit-1 HPCI system failed to meet required system |
| response time during surveillance testing. Testing was being performed to |
| establish HPCI operability during reactor startup with reactor steam dome |
| pressure at 204 psig. The HPCI system failed to achieve rated system flow |
| within the required time from system initiation. Troubleshooting is |
| currently in progress and a determination is underway to determine if this |
| problem was related to maintenance activities performed during the refueling |
| outage. |
| |
| "This report is being made in pursuant to 10CFR50.72(b)(3)(v)(D) for failure |
| of a single train accident mitigation system." |
| |
| The licensee notified the NRC Resident Inspector. |
| |
| ***UPDATE (EVENT RETRACTION) 4/3/02 at 1533 from Stan Gamble to Rich |
| Laura*** |
| |
| "This is a retraction of the event notification made on 3/20/02 at 22:56 |
| hours. This event (#38790) was initially reported as a safety system |
| functional failure under the requirement of 1OCFR5O.72(b)(3)(v)(D). Unit 1 |
| High Pressure Coolant Injection (HPCI) failed to meet the required system |
| maximum response time during surveillance testing. Testing was being |
| performed during reactor startup with reactor steam dome pressure at 204 |
| psig. |
| |
| "Rated flow was not achieved within the 59-second maximum response time |
| specified in the test due to motor operated valve (MOV) and flow controller |
| manipulations performed during the unsatisfactory testing. The test was |
| re-performed successfully and the system was declared operable on 2/21/02 at |
| 02:15 hours. System repair was not required. |
| |
| "The system response was verified to be as designed considering the test |
| conditions. A condition did not exist at the time of discovery that could |
| have prevented the fulfillment of the safety function." |
| |
| Notified R1DO (G. Meyer) |
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|Power Reactor |Event Number: 38825 |
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| FACILITY: ARKANSAS NUCLEAR REGION: 4 |NOTIFICATION DATE: 04/03/2002|
| UNIT: [1] [2] [] STATE: AR |NOTIFICATION TIME: 11:34[EST]|
| RXTYPE: [1] B&W-L-LP,[2] CE |EVENT DATE: 04/03/2002|
+------------------------------------------------+EVENT TIME: 08:27[CST]|
| NRC NOTIFIED BY: TOM SCOTT |LAST UPDATE DATE: 04/03/2002|
| HQ OPS OFFICER: GERRY WAIG +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |BILL JONES R4 |
|10 CFR SECTION: | |
|HFIT 26.73 FITNESS FOR DUTY | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| FITNESS FOR DUTY REPORT INVOLVING CONTRACT SUPERVISOR |
| |
| A non-licensed contractor supervisor tested positive for alcohol during a |
| for-cause fitness for duty test. The individual's site unescorted access has |
| been removed. Contact the Headquarters Operations Officer for additional |
| information. |
| |
| The NRC Resident Inspector was notified of the event by the licensee. |
| |
| The licensee also notified NRC Region 4 (Dennis Schaefer) of the event. |
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|Fuel Cycle Facility |Event Number: 38826 |
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| FACILITY: FRAMATOME ANP RICHLAND |NOTIFICATION DATE: 04/03/2002|
| RXTYPE: URANIUM FUEL FABRICATION |NOTIFICATION TIME: 17:05[EST]|
| COMMENTS: LEU CONVERSION |EVENT DATE: 04/03/2002|
| FABRICATION & SCRAP RECOVERY |EVENT TIME: [PST]|
| COMMERCIAL LWR FUEL |LAST UPDATE DATE: 04/03/2002|
| CITY: RICHLAND REGION: 4 +-----------------------------+
| COUNTY: BENTON STATE: WA |PERSON ORGANIZATION |
|LICENSE#: SNM-1227 AGREEMENT: Y |BILL JONES R4 |
| DOCKET: 07001257 |PATRICIA HOLAHAN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: CALVIN MANNING | |
| HQ OPS OFFICER: RICH LAURA | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| NRC BULLETIN 91-01 (CRITICALITY CONTROLS) ISSUE AT FRAMATONE ANP RICHLAND
|
| |
| "Background: FRA-ANP routinely uses 45-gallon drums that contain a neutron |
| absorbing spider assembly for processing and storing unmoderated urania |
| powder. The spider assembly is inserted into the drum and bolted to the |
| drum bottom. This spider assembly is designed such that it will prevent |
| criticality in a single drum even if the drum is accidentally filled with an |
| optimum mixture of UO2 and water and is also fully reflected by water. |
| Accidental disassembly is prevented by the spider assembly design. However, |
| when a drum reaches the end of useful service, or if the drum will no longer |
| be used for dirty or Gd contaminated powder, the neutron absorbing spider |
| assembly is removed and reused with a new 45-gallon drum. The old drum sans |
| insert is then destroyed. |
| |
| "Event Description: On swing shift April 2, 2002 process operators removed |
| the neutron absorbing spider assemblies from three 45-gallon drums per |
| standard operating procedure (SOP). Operators moved these three drums to the |
| old waste area. |
| |
| "Around midnight, a process operator retrieved one of the 45-gallon drums in |
| the old waste area instead of going to the powder storage area to retrieve a |
| 45-gallon drum. He transferred it to a nearby utility hood and used it to |
| prepare a blend of unmoderated dirty urania powder for subsequent |
| dissolution. The process operator failed to perform a required visual |
| inspection of the interior of the 45-gallon drum prior to transferring 250 |
| kg of urania powder enriched to 2.7 wt.% 235U into it. The same process |
| operator secured the lid and transferred it per SOP to another process |
| enclosure where the drum lid is removed and a drum tumbling lid is |
| installed. When the process operator removed the drum lid at about 0230, he |
| noticed the drum did not have a neutron absorbing spider assembly and |
| contacted supervision. Supervision immediately contacted Criticality |
| Safety. |
| |
| "Safety Significance of Event: The safety significance of this event is low. |
| The urania powder placed in this drum was known in advance to contain less |
| than 1 wt.% moisture equivalent hydrogen. Two process operators had |
| previously verified the material had acceptable laboratory analysis results |
| and that the correct material had been selected for the blend. |
| |
| "A sphere of 250 kg UO2 powder enriched to 5 wt.% 235U, with a bulk density |
| of 4 g/cc, and containing 10 wt.% water that is fully reflected by water |
| has a keff of 0.95. Therefore, the material in the drum would have to have |
| more than 10 times the limit before criticality could occur in the drum. |
| |
| "Potential Criticality Pathways Involved (Brief Scenario(s) Of How |
| Criticality Could Occur): Criticality could only occur if moderation control |
| on the material placed in the drum is lost. This could hypothetically occur |
| if powder containing over 10 times the allowed limit were placed into the |
| drum or if a similar amount liquid water entered a drum from an external |
| source. |
| |
| "Controlled Parameters (Mass, Moderation, Geometry, Concentration, Etc.): |
| The process parameter controlled in this portion of the process is |
| moderation. An additional design control is the neutron absorbing insert. |
| When installed, this insert will keep the drum sub-critical even if |
| moderation control is completely lost in a single drum. |
| |
| "Estimated Amount, Enrichment, Form of Licensed Material ( Include Process |
| Limit and % Worst Case Critical Mass): |
| The amount of material involved is 250 kg of urania powder enriched to 2.7 |
| wt.% 235U. The material contained <0.2 wt.% moisture. The process limit is |
| 1.0 wt.% moisture. More than 10 wt.% water and a full water reflector is |
| required for keff to exceed 0.95 at 5.0 wt.% 235U. |
| |
| "The minimum critical mass for optimally moderated urania powder enriched to |
| 2.75 wt.% 235U with full water reflection is about 124 kg. |
| |
| "Nuclear Criticality Safety Control(s) or Control System(s) and Description |
| of the Failures or Deficiencies: |
| The moderator control system requires that any material placed into a |
| 45-gallon drum have at least on assurance that the material contains less |
| than 1.0 wt.% moisture. The moderation control system includes two |
| operators verifying that acceptable lab analysis results have been obtained |
| and that the correct material has been selected for being dumping into a |
| 45-gallon drum. These operators are also aided by a computer controlled |
| inventory system that also checks for acceptable moisture results on each |
| item being placed on a blend make up list. |
| |
| "In addition to moderation control, the neutron adsorbing spider assemblies |
| will keep the drum subcritical even if it is filled with optimally moderated |
| UO2. This control failed because a drum without the required insert was |
| inadvertently used in the process. This occurred because the process |
| operator failed to perform a required visual inspection prior to filling the |
| drum. Also, the operating procedure for disassembling 45-gallon drums with |
| neutron absorbing spider assemblies did not require an out of service sign |
| to be posted on the drum. |
| |
| "Corrective Actions To Restore Safety Systems and When Each Was Implemented: |
| Manager of Criticality Safety convened an Incident Investigation Board at |
| 0330. |
| |
| "The material involved was transferred to a drum containing a neutron |
| absorbing spider assembly and handled per standard operating procedures. |
| The transfer was completed by 0615. |
| |
| "All drums that do not contain neutron absorbing spider assemblies were |
| tagged with out-of-service signs and then removed from the area and smashed. |
| |
| |
| "Drum disassembly, and blend make-up operations have been placed on hold |
| pending completion of procedure revisions and training. |
| |
| "Additional corrective actions are being evaluated." |
| |
| Framatome notified Region 4 (B. SPITZBERG). |
+------------------------------------------------------------------------------+
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|Fuel Cycle Facility |Event Number: 38827 |
+------------------------------------------------------------------------------+
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| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE:
04/03/2002|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 15:54[EST]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 04/03/2002|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 11:59[EST]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 04/03/2002|
| CITY: PIKETON REGION: 3 +-----------------------------+
| COUNTY: PIKE STATE: OH |PERSON ORGANIZATION |
|LICENSE#: GDP-2 AGREEMENT: N |DAVID HILLS R3 |
| DOCKET: 0707002 |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: RICK LARSON | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| SEGMENTED GAMMA SCANNER (SGS) APPEARS TO GIVE LOWER THAN ACTUAL
MASS VALUES |
| COMPARED WITH THE LOW DENSITY WASTE ASSAY MONITOR (LDWAM) MASS
VALUES. |
| |
| NRC BULLETIN 91-01 4 HOUR NOTIFICATION |
| |
| "At 1159 hours today after Nuclear Materials Engineering completed a review |
| of their databases for batched items stored in 55 gal. drums, it was |
| discovered that 26 drums with questionable Segmented Gamma Scanner (SGS) |
| values were located in the XT-847. The concern about the SGS not correctly |
| counting the U-235 mass was identified earlier but at that time no drums |
| were identified in the United States Enrichment Corporation (USEC) leased |
| spaces. The mass counting error identified between the SCS and the Low |
| Density Waste Assay Monitor (LDWAM) was at times off by a factor of 10 or |
| more. Because of the questionable SGS measurements it could not be assured |
| the 350 gram U-235 limit per batched drum was maintained. The governing NSCA |
| X-0847_ 001. A04 Operation of the XT-847 Facility in it's NCSE accounted for |
| an error of a factor of two in mass calculations, as a bounding condition. |
| Thus with the loss of the bounding calculations and the potential error in |
| mass calculations, this resulted in the loss of both legs of the double |
| contingency basis (mass & the factor of two bounding error) for NCSA |
| X-847_001.A04. At the present time Waste Material handlers in the XT-847 |
| are moving all 26 drums from their storage area to another storage location |
| within the building to allow for remeasurement of the drums. The guidance |
| for moving and relocating these drums for remeasurement is covered by |
| existing procedures and NCSAs. |
| |
| "SAFETY SIGNIFICANCE OF EVENTS: The safety significance of this event is low |
| because the actual uranium mass content of the drums in question would not |
| be expected to contain more than a safe amount of uranium bearing material. |
| Other similar drums of trappIng material batched during the same period |
| using LDWAM measurements contain considerably less than a safe mass of |
| U-235. The uranium mass limits assume optimum moderation and 100% |
| enrichment. The drums in question are known to contain less than 10% |
| enrichment (based upon process knowledge or sampling) and the material |
| stored in the XT-847 is dry trapping material (alumina, etc). Even with the |
| maximum potential error in the SGS measurements, the total mass in any drum |
| (or group) would be less than the safe mass of uranium at an H/U of 4 (wet |
| air moderation of approximately 7.9 kg of U-235 (100% enrichment) |
| |
| "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW |
| CRITICALITY COULD OCCUR): |
| For a criticality to occur, the following events would be required: One or |
| more drums must contain greater than a minimum critical mass of uranium (at |
| this time, the measurement results are in question, but greater than a safe |
| mass has not actually been measured in any drum), the contents of the drums |
| would need to be moderated by water or oil (the material is dry trapping |
| material), and some amount of reflection would be required (for the drums, |
| or groups of drums, currently spaced 2 feet edge-to-edge apart). |
| |
| "CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY. CONCENTRATION,
ETC.): |
| The drums were filled by batching small diameter containers of trapping |
| material based upon NDA or sample measurements of the uranium mass present. |
| The batching limits are 43.5% of the minimum critical mass assuming optimum |
| moderation, concentration, geometry, reflection, etc. In the applicable |
| NCSE, credit is taken for a double batch scenario bounding potential uranium |
| mass upsets; however, the potential error in the SGS measurements may be |
| greater than a factor of two. Spacing is controlled for drums, or groups of |
| drums, unless categorized as containing less than 15 grams U-235. |
| |
| "ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE
PROCESS |
| LIMIT AND % WORST CASE OF CRITICAL MASS): The contents of the drums are dry |
| trapping material from the cascade buildings, and are known to be enriched |
| to 10% or less. At the time they were filled, the total mass was calculated |
| to be less than 350 grams U-235. However, the SGS used to measure source |
| containers has been questioned. The variability of the SGS results indicate |
| that the total uranium mass in containers batched into a drum could be |
| non-conservative by a factor of 10 or more. |
| |
| "NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND
DESCRIPTION |
| OF THE FAILURES OR DEFICIENCIES: Recent NDA measurements performed on the |
| Low Density Waste Assay Monitor (LDWAM) have identified discrepancies in the |
| gram quantity of U-235 when compared to the Segmented Gamma Scanner (SGS) |
| measured values (see PR-PTS-02-01398). The SGS values are biased low which |
| could have resulted in underestimatlng the total batch quantity for |
| previously batched drums. Until confirmatory measurements of the drums are |
| obtained, the potential mass content represents a loss of both legs of |
| double contingency as described in the applicable NCSE. |
| |
| "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS
IMPLEMENTED: |
| These drums are not safety systems but corrective actions to regain |
| compliance was started at 1530 hours 4/2/02." |
| |
| The NRC Resident Inspector was notified by the certificate holder. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 38828 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ILLINOIS DEPT OF NUCLEAR SAFETY |NOTIFICATION DATE: 04/03/2002|
|LICENSEE: RUSH-PRESBYTERIAN-ST. LUKE'S MEDICAL |NOTIFICATION TIME:
16:05[EST]|
| CITY: REGION: 3 |EVENT DATE: 10/17/2001|
| COUNTY: STATE: IL |EVENT TIME: [CST]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 04/03/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID HILLS R3 |
| |PATRICIA HOLAHAN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: THOMAS SEIF | |
| HQ OPS OFFICER: RICH LAURA | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT OF MEDICAL MISADMINISTRATION |
| |
| "On October 17, 2001 a patient was being treated with a P-32 impregnated |
| balloon. This balloon is part of an FDA study sponsored by Radiance. This |
| treatment is designed to be a sequence of inflations and deflations at the |
| treatment site. During the record review on March 21, 2001, the patient was |
| feeling significant discomfort, so the Doctor ordered for the balloon to be |
| deflated. Since there was a deviation in protocol, all records were |
| appropriately documented. |
| |
| "During the record review on March 21, 2002, it was noted that the order for |
| the treatment to be given in the deflated state was approximately half of |
| the original order. The order was supposed to be that the entire treatment |
| time would be in the deflated stage, but unfortunately, only the deflated |
| stage was administered. The dose was approximately 11 Gy (55%) of the |
| original order of 20 Gy. No other deviations were noted. |
| |
| "The patient and primary physician have been notified. Procedures are in the |
| process of being reviewed to ensure future compliance. The name and |
| identification number of the patient involved has been attached on a |
| separate sheet." |
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Page Last Reviewed/Updated Wednesday, March 24, 2021