| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
12/29/2003 - 12/30/2003 ** EVENT NUMBERS ** |
 | General Information or Other | Event Number: 40413 | Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: SOUTHWEST GENERAL HEALTH CENTER-IRELAND CANCER CENTER
Region: 3
City: MIDDLEBURG HEIGHTS State: OH
County:
License #: 02120180001
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: GERRY WAIG | Notification Date: 12/24/2003
Notification Time: 09:34 [ET]
Event Date: 12/22/2003
Event Time: 13:00 [EST]
Last Update Date: 12/24/2003 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
PATRICK LOUDEN (R3)
TOM ESSIG (NMSS)
| Event Text OHIO AGREEMENT STATE REPORT - RADIATION DOSE TO UNINTENDED SITE DURING BRACHYTHERAPHY TREATMENT
On 12/23/2003 at 1600 hours EST the licensee notified the Ohio Department of Health, Bureau of Radiation Protection, of the following information regarding a patient undergoing intravascular brachytheraphy treatment:
"On December 22, 2003 during a treatment with a Novoste Beta-Cath 3.5 French IVB System, the source did not travel the entire way to the treatment site and was 3 centimeters proximal to the treatment site. The immediate cause of the event was a small kink in the delivery catheter which kept the source train from traveling to the correct site, even though the kink was not substantial enough to affect the flow of sterile water used to send/retrieve the sources. The error was discovered the next day during medical physics quality checks and reported to Ohio Department of Health, Bureau of Radiation Protection. An investigation will be performed the week of December 29, 2003."
The dose to the unintended site was identified as 1840 rad (18.4 Gy) from a 0.05378 curie, Sr-90, sealed source. The attending physician has been notified. The intravascular brachytheraphy unit is a Novoste, model TDA-1040, serial number 91828.
The Ohio Department of Health, Bureau of Radiation Protection reference number for this event is 2003-126. |
| Power Reactor | Event Number: 40417 | Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [1] [2] [ ]
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: KENN TATE
HQ OPS Officer: CHAUNCEY GOULD | Notification Date: 12/29/2003
Notification Time: 16:49 [ET]
Event Date: 12/29/2003
Event Time: 11:29 [CST]
Last Update Date: 12/29/2003 | Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
| Person (Organization):
Tom Farnholtz (R4)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 100 | Power Operation | 100 | Power Operation | | 2 | N | Y | 18 | Power Operation | 18 | Power Operation | Event Text POSITIVE TEST DURING A RANDOM FITNESS FOR DUTY SCREENING
Non - licensed, non-supervisory employee tested positive for presence of alcohol.
The NRC Resident Inspector was notified. | |