Event Notification Report for January 14, 2006
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/13/2006 - 01/14/2006
EVENT NUMBERS
42270
General Information or Other
Event Number: 42270
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CHARLOTTE MECKLENBURG HOSPITAL AUTHORITY
Region: 1
City: CHARLOTTE State: NC
County:
License #: 060-0014-3
Agreement: Y
Docket:
NRC Notified By: J. MARION EADDY III
HQ OPS Officer: BILL GOTT
Licensee: CHARLOTTE MECKLENBURG HOSPITAL AUTHORITY
Region: 1
City: CHARLOTTE State: NC
County:
License #: 060-0014-3
Agreement: Y
Docket:
NRC Notified By: J. MARION EADDY III
HQ OPS Officer: BILL GOTT
Notification Date: 01/18/2006
Notification Time: 17:38 [ET]
Event Date: 01/14/2006
Event Time: 00:00 [EST]
Last Update Date: 01/18/2006
Notification Time: 17:38 [ET]
Event Date: 01/14/2006
Event Time: 00:00 [EST]
Last Update Date: 01/18/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHRIS HOTT (R1)
LAWRENCE KOKAJKO (NMSS)
CHRIS HOTT (R1)
LAWRENCE KOKAJKO (NMSS)
AGREEMENT STATE REPORT - MEDICAL EVENT
The State provided the following information via fax:
"N.C. Radiation Protection Section was notified on 18 Jan 2006 by the RSO for the Charlotte Mecklenburg Hospital Authority of a misadministration during a manual brachytherapy treatment. The authorized user's written directive called for a temporary implant 'tandem and ovoid' using Cs-137 sources to deliver a total dose of 4883 RAD (approximately 49Gy) over 68 hours, with following source loading in the applicator:
"Right Ovoid: 1 at 14.6 mgRaEq [milligram Radium Equivalent] (approximately 51.1 mCi or 1891 MBq)
Left Ovoid: 1 at 14.6 mgRaEq
Tandem: 1 at 11.2 mgRaEq (approximately 39.2 mCi or 1450 MBq), 2 at 14.6 mgRaEq
"A medical dosimetrist loaded the tandem and ovoid incorrectly. The actual loading of the applicator was:
"Right Ovoid: 1 at 14.6 mgRaEq (approximately 51.1 mCi or 1891 MBq)
Left Ovoid: 1 at 14.6 mgRaEq
Tandem: 1 at 11.2 mgRaEq (approximately 39.2 mCi or 1450 MBq), 2 at 24.8 mgRaEq (approximately 86.8 mCi or 3212 MBq)
"This errant loading of applicator resulted in the patient receiving 6474 RAD (approximately 65 Gy) to the treatment area. The delivered dose was 33 percent more than prescribed.
"The Cs-137 sources utilized in the procedure were:
"3M Model 6503 (14.6 mgRaEq)
3M Model 6502 (11.2 mgRaEq)
AEA Technology/QSA Model CDC.T1 (24.8 mgRaEq)
"The licensee is conducting follow-up investigations and will make a report the Radiation Protection Section within 15 days of the discovery of the event. The report will contain root cause analysis and procedures to prevent recurrence.
"N.C. Radiation Protection has not received any media attention as of this report. No press release has been issued."
Event Report ID No.: NC-06-04
The State provided the following information via fax:
"N.C. Radiation Protection Section was notified on 18 Jan 2006 by the RSO for the Charlotte Mecklenburg Hospital Authority of a misadministration during a manual brachytherapy treatment. The authorized user's written directive called for a temporary implant 'tandem and ovoid' using Cs-137 sources to deliver a total dose of 4883 RAD (approximately 49Gy) over 68 hours, with following source loading in the applicator:
"Right Ovoid: 1 at 14.6 mgRaEq [milligram Radium Equivalent] (approximately 51.1 mCi or 1891 MBq)
Left Ovoid: 1 at 14.6 mgRaEq
Tandem: 1 at 11.2 mgRaEq (approximately 39.2 mCi or 1450 MBq), 2 at 14.6 mgRaEq
"A medical dosimetrist loaded the tandem and ovoid incorrectly. The actual loading of the applicator was:
"Right Ovoid: 1 at 14.6 mgRaEq (approximately 51.1 mCi or 1891 MBq)
Left Ovoid: 1 at 14.6 mgRaEq
Tandem: 1 at 11.2 mgRaEq (approximately 39.2 mCi or 1450 MBq), 2 at 24.8 mgRaEq (approximately 86.8 mCi or 3212 MBq)
"This errant loading of applicator resulted in the patient receiving 6474 RAD (approximately 65 Gy) to the treatment area. The delivered dose was 33 percent more than prescribed.
"The Cs-137 sources utilized in the procedure were:
"3M Model 6503 (14.6 mgRaEq)
3M Model 6502 (11.2 mgRaEq)
AEA Technology/QSA Model CDC.T1 (24.8 mgRaEq)
"The licensee is conducting follow-up investigations and will make a report the Radiation Protection Section within 15 days of the discovery of the event. The report will contain root cause analysis and procedures to prevent recurrence.
"N.C. Radiation Protection has not received any media attention as of this report. No press release has been issued."
Event Report ID No.: NC-06-04