Event Notification Report for August 04, 2005
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/03/2005 - 08/04/2005
EVENT NUMBERS
41925
General Information or Other
Event Number: 41925
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: UNIVERSITY OF UTAH
Region: 4
City: SALT LAKE CITY State: UT
County:
License #: UT 1800001
Agreement: Y
Docket:
NRC Notified By: JULIE FELICE
HQ OPS Officer: BILL GOTT
Licensee: UNIVERSITY OF UTAH
Region: 4
City: SALT LAKE CITY State: UT
County:
License #: UT 1800001
Agreement: Y
Docket:
NRC Notified By: JULIE FELICE
HQ OPS Officer: BILL GOTT
Notification Date: 08/17/2005
Notification Time: 18:57 [ET]
Event Date: 08/04/2005
Event Time: 11:30 [MST]
Last Update Date: 08/17/2005
Notification Time: 18:57 [ET]
Event Date: 08/04/2005
Event Time: 11:30 [MST]
Last Update Date: 08/17/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GARY SANBORN (R4)
JOSEPH HOLONICH (NMSS)
GARY SANBORN (R4)
JOSEPH HOLONICH (NMSS)
AGREEMENT STATE REPORT - MEDICAL EVENT
The State provided the following information via facsimile:
"This event involved an HDR brachytherapy unit [Nucletron Corporation Model 105.999, serial number 31062; with sealed source Nucletron Corporation Model 105.002, serial number D36A-7277]. The maximum activity that can be utilized in the unit is 444 gigabecquerels (12 Curies) of Ir-192. The male patient was receiving palliative treatment for metastatic disease. On August 4, 2005, the patient received the second of the three prescribed treatments to the left bronchus. The licensee's Medical Physicist discovered the error on August 10, 2005. The error was a contiguous shift lengthwise of 3 centimeters from the area that was being treated. The intended fraction was 7 Gray. The patient and the referring physician were notified on August 11, 2005. The licensee is still in the process of evaluating the event. The licensee is to submit a written report to the Utah Division of Radiation Control. The treating physician determined that there will be no adverse affect to the patient as a result of this event and that diseased tissue may have been treated. The Division of Radiation Control is still investigating this event."
Event Report ID Number: UT-05-0006
The State provided the following information via facsimile:
"This event involved an HDR brachytherapy unit [Nucletron Corporation Model 105.999, serial number 31062; with sealed source Nucletron Corporation Model 105.002, serial number D36A-7277]. The maximum activity that can be utilized in the unit is 444 gigabecquerels (12 Curies) of Ir-192. The male patient was receiving palliative treatment for metastatic disease. On August 4, 2005, the patient received the second of the three prescribed treatments to the left bronchus. The licensee's Medical Physicist discovered the error on August 10, 2005. The error was a contiguous shift lengthwise of 3 centimeters from the area that was being treated. The intended fraction was 7 Gray. The patient and the referring physician were notified on August 11, 2005. The licensee is still in the process of evaluating the event. The licensee is to submit a written report to the Utah Division of Radiation Control. The treating physician determined that there will be no adverse affect to the patient as a result of this event and that diseased tissue may have been treated. The Division of Radiation Control is still investigating this event."
Event Report ID Number: UT-05-0006