Event Notification Report for January 13, 2003

DAMAGED IODINE-125 SEED RESULTS IN DOSE THAT DIFFERS FROM PRESCRIBED DOSE BY >20 %

"On Monday January 13, 2003 a prostate implant was performed on [DELETED]. The seeds that were used were Amersham's Echoseed. Each seed had an activity of 0.472 [millicurie] apparent activity (NIST 1999) on the day of the implant. The actual activity is 1.78 times the apparent activity which results in an actual activity of 0.84 [millicurie].

"During the implant there was difficulty in removing a cartridge. Once the cartridge was removed, there was some activity that registered in the Mick gun. A blood clot that registered radioactivity was expelled from the gun and was isolated and the implant proceeded. This involved the last seed in a Mick disposable cartridge.

"Once the implant was completed, the blood clot was examined and was found to contain a fragment of a seed. The entire operating room was checked carefully to see if the other portion of the seed was anywhere on the operating room. There was no contamination found in any of the instruments or in any of the used cartridges with the GM probe. No seeds or any activity was discovered during cystography or in any of the trash in the operating room. The feet of all the individuals involved in the procedure were checked in case a seed adhered to a shoe covering. It was assumed that the remainder of the seed was placed in the patient's prostate. The radiation oncologist ordered that the patient be given a blocking dose of iodine in the form of Lugol's solution. The radiation oncologist informed the patient that he was being placed on this medication because of the possibility that a leaking seed was implanted."

The prescribing physician has informed the patient.

* * * UPDATE ON 1/16/03 AT 1123 BY SHABASONS TO GOULD * * *

The licensee originally reported this event under 10 CFR 35.3045(a)(1) and called to change it to 10 CFR 35.3045(a)(2). The licensee estimates that the thyroid dose is <5 Rem.

The NRC Headquarters Operations Officer notified the R1DO (Richard Barkley) of this update.

AGREEMENT STATE REPORT INVOLVING LOST SOURCES

The Licensee reported the loss of five 0.355 microcurie, I-125 brachytherapy seeds. The seeds were model # IAI-125A and they were inventoried upon receipt from the manufacturer, Iso-Aid. The seeds were being washed prior to sterilization (this is a deviation from procedure) and the licensee believes they were washed down the drain to the public sewer system. The Licensee reports that surveys do not indicate that they are in the sink or trap.

***UPDATE 01/15/03 1202 EST MIKE BRODERICK TO MIKE NORRIS***

The seeds are actually 0.355 millicurie sources. Notified NMSS (Brown) and R4DO (Sanborn).

MANUAL REACTOR TRIP DUE TO LOSS OF CONDENSER CIRCULATING WATER PUMP

At 0618 EST the #35 Circulating Water Pump tripped. The other circulating water pump supplying the same condenser section was out of service for maintenance. The resulting loss of all circulating water to one condenser section produced a high differential pressure between sections. The reactor was manually tripped in accordance with plant procedures. All controlled rods fully inserted. The Auxiliary Feedwater Pump automatically started as expected. During the transient, the #32 Reactor Coolant Pump tripped due to an unknown cause and is being investigated. Additionally, the # R14 Plant Vent Gas radiation monitor went into alarm and then immediately returned to normal, however the redundant monitor did not show any increase in radiation. Additionally, the #32 Source Range Detector did not come on scale on the reactor trip, however the redundant detector functioned normally. The electrical system responded normally. There were no releases associated with this event. The cause of the circulating water pump trip is under investigation.

The licensee has notified the NRC resident inspector.