Event Notification Report for November 20, 2002
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/19/2002 - 11/20/2002
EVENT NUMBERS
39415
General Information or Other
Event Number: 39415
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: CARTI-UAMS
Region: 4
City: LITTLE ROCK State: AR
County:
License #: 930-BP-04-09
Agreement: Y
Docket:
NRC Notified By: JARED THOMPSON
HQ OPS Officer: ERIC THOMAS
Licensee: CARTI-UAMS
Region: 4
City: LITTLE ROCK State: AR
County:
License #: 930-BP-04-09
Agreement: Y
Docket:
NRC Notified By: JARED THOMPSON
HQ OPS Officer: ERIC THOMAS
Notification Date: 12/02/2002
Notification Time: 15:50 [ET]
Event Date: 11/20/2002
Event Time: 00:00 [CST]
Last Update Date: 12/02/2002
Notification Time: 15:50 [ET]
Event Date: 11/20/2002
Event Time: 00:00 [CST]
Last Update Date: 12/02/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WILLIAM JONES (R4)
THOMAS ESSIG (NMSS)
WILLIAM JONES (R4)
THOMAS ESSIG (NMSS)
AGREEMENT STATE REPORT INVOLVING MEDICAL MISADMINISTRATION
"A medical misadministration was reported to Arkansas Department of Health Radiation Control and Emergency Management's Radioactive Materials Program by CARTI-UAMS on November 27, 2002 via a voice mail message. Due to the Thanksgiving holiday, the message was not reviewed by the Department until December 2, 2002.
"According to the voice mail message and the preliminary telephone interview with the licensee, the misadministration resulted from the incorrect positioning of a treatment tandem within the cervical treatment cylinder. As a result, the treatment was delivered approximately 3 cm inferior to the intended position. The incorrect positioning of the tandem that occurred during first treatment on November 20, 2002 was noted when the medical physics staff was reviewing the position verification film for the second treatment on November 27, 2002.
"An onsite investigation will be conducted by the Department on December 2, 2002. An updated report of the medical misadministration will be provided following this investigation."
"A medical misadministration was reported to Arkansas Department of Health Radiation Control and Emergency Management's Radioactive Materials Program by CARTI-UAMS on November 27, 2002 via a voice mail message. Due to the Thanksgiving holiday, the message was not reviewed by the Department until December 2, 2002.
"According to the voice mail message and the preliminary telephone interview with the licensee, the misadministration resulted from the incorrect positioning of a treatment tandem within the cervical treatment cylinder. As a result, the treatment was delivered approximately 3 cm inferior to the intended position. The incorrect positioning of the tandem that occurred during first treatment on November 20, 2002 was noted when the medical physics staff was reviewing the position verification film for the second treatment on November 27, 2002.
"An onsite investigation will be conducted by the Department on December 2, 2002. An updated report of the medical misadministration will be provided following this investigation."