Event Notification Report for December 13, 2001
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/12/2001 - 12/13/2001
General Information or Other
Event Number: 38582
Rep Org: COLORADO DEPT OF HEALTH
Licensee: EXEMPLA ST. JOSEPH HOSPITAL
Region: 4
City: DENVER State: CO
County:
License #: 38-33A
Agreement: Y
Docket:
NRC Notified By: EGIDI
HQ OPS Officer: CHAUNCEY GOULD
Licensee: EXEMPLA ST. JOSEPH HOSPITAL
Region: 4
City: DENVER State: CO
County:
License #: 38-33A
Agreement: Y
Docket:
NRC Notified By: EGIDI
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 12/19/2001
Notification Time: 10:36 [ET]
Event Date: 12/13/2001
Event Time: 00:00 [MST]
Last Update Date: 12/19/2001
Notification Time: 10:36 [ET]
Event Date: 12/13/2001
Event Time: 00:00 [MST]
Last Update Date: 12/19/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GARY SANBORN (R4)
DON COOL (NMSS)
GARY SANBORN (R4)
DON COOL (NMSS)
THE COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT REPORTED A POSSIBLE MEDICAL MISADMINISTRATION BY ONE OF THEIR LICENSEES
This occurred during a therapeutic administration of strontium - 90 when the catheter being used shifted about 15 mm and ended up in the aorta instead of a blood vessel. When the catheter was initially placed and the sources were driven out, on the initial 30 second check everything was ok, but on the second 30 second check, the catheter looked like it had moved, so the source was retracted and the catheter repositioned. The source was out for approximately 1 minute 15 seconds. After the repositioning the full treatment(23 gray) was given to the patient. The patient was notified through the referring physician.
This occurred during a therapeutic administration of strontium - 90 when the catheter being used shifted about 15 mm and ended up in the aorta instead of a blood vessel. When the catheter was initially placed and the sources were driven out, on the initial 30 second check everything was ok, but on the second 30 second check, the catheter looked like it had moved, so the source was retracted and the catheter repositioned. The source was out for approximately 1 minute 15 seconds. After the repositioning the full treatment(23 gray) was given to the patient. The patient was notified through the referring physician.
General Information or Other
Event Number: 38560
Rep Org: CARBOLINE COMPANY
Licensee: CARBOLINE COMPANY
Region: 3
City: BRENTWOOD State: MO
County:
License #:
Agreement: N
Docket:
NRC Notified By: RICHARD MIDDEKE
HQ OPS Officer: JOHN MacKINNON
Licensee: CARBOLINE COMPANY
Region: 3
City: BRENTWOOD State: MO
County:
License #:
Agreement: N
Docket:
NRC Notified By: RICHARD MIDDEKE
HQ OPS Officer: JOHN MacKINNON
Notification Date: 12/13/2001
Notification Time: 16:06 [ET]
Event Date: 12/13/2001
Event Time: 12:00 [CST]
Last Update Date: 12/13/2001
Notification Time: 16:06 [ET]
Event Date: 12/13/2001
Event Time: 12:00 [CST]
Last Update Date: 12/13/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
CLIFFORD ANDERSON (R1)
ANNE MARIE STONE (R3)
CLIFFORD ANDERSON (R1)
ANNE MARIE STONE (R3)
CARBOZINC 11 SG HAS BEEN DETERMINED TO HAVE A REPORTABLE DEFECT.
Carboline has been notified of stability problems with some Carbozinc 11 SG product over the last year. The material is exhibiting premature gellation or thickening prior to the end of the published shelf life expiration date. Carbozinc 11 SG that is gelled or exhibiting significant thickening will not atomize or spray properly, resulting in poor adhesion to the substrate. When this occurs the coating cracks during the spray process and the coating process and the coating flakes off the substrate.
On December 14, 2001, Carboline will send by register mail to all purchasers of Carbozinc 11 SG reporting Part 21 Reporting of Defect.
See event number 38408, reported 10/19/2001 for background information.
Carboline has been notified of stability problems with some Carbozinc 11 SG product over the last year. The material is exhibiting premature gellation or thickening prior to the end of the published shelf life expiration date. Carbozinc 11 SG that is gelled or exhibiting significant thickening will not atomize or spray properly, resulting in poor adhesion to the substrate. When this occurs the coating cracks during the spray process and the coating process and the coating flakes off the substrate.
On December 14, 2001, Carboline will send by register mail to all purchasers of Carbozinc 11 SG reporting Part 21 Reporting of Defect.
See event number 38408, reported 10/19/2001 for background information.