Event Notification Report for November 19, 2007

SPILL OF SEWAGE SLUDGE

"At approximately 1100 hours on November 19, 2007, waste treatment operators noticed that the sewage sludge pump transferring material to the LLR press, located at the Waste Treatment Facility, had split and that sludge material had been released. The volume of sludge material that was released is estimated to be less than 150 gallons. The material was released in the pump house and flowed to a gravel area north of the pump house and extended into a storm water drainage ditch. A small quantity of material appeared to collect in the ditch, but did not flow off-site. Operators contained the spilled material and cleaned the affected areas in less than 24 hours.

"Facility sewage is of low activity due to natural content and the possible presence of trace material due to trace contamination in the associated piping system. The material is known to be << [much less than] 30 pCi/g [picoCuries per gram]. The total activity spilled including natural background is estimated to be less than 6 uCi [microCuries] using a maximum concentration of 10 pCi/g and 150 gallons of material. Both values are conservative. A study is in progress to determine if licensed material was actually present.

"On November 20,2007, as required by our VPDES Permit Number 0003697, the Virginia Department of Environmental Quality was notified of this non-permitted release to the environment.

"BWXT is making this concurrent notification in accordance with 10 CFR 70 Appendix A(c)."

There was no other potentially hazardous material released.

The licensee notified the NRC Resident Inspector.

AGREEMENT STATE - PATIENT RECEIVED 10% OF PRESCRIBED DOSE

"Medical physicist for the licensee called to advise that on Wednesday November 21, it had come to his attention that a medical event had occurred at their Winfield, IL facility. He reported that on beginning Monday November 19, the delivered dose per fraction was only one tenth that which was originally prescribed by the oncologist. The original written directive was to have a post surgical total dose of 3400 cGy delivered in 10 fractions over the course of 5 days (2 per day). However when reviewed by the medical physicist, the treatment protocol instead indicated that each fraction was 34 cGy instead of the 340 cGy per fraction. The attending oncologist we immediately notified and treatments suspended. As a result the dose administered was well below 20% of the intended dose as well as less than 50% per each fraction.

"At the time of the assessment only 6 fractions had been conducted and a total dose of 192 cGy had been delivered. After notifying the oncologist and the patient the same day the error was noted, it was determined that the treatment provided to date was an ineffective post surgical procedure and the patient should be retreated. A revised treatment plan was prepared and the first six fractions of a revised 10 fraction treatment have been completed at this time. The oncologist believes there is no end medical effect that will be noticed from this event.

"Upon review, the treatment team determined that the dosimetrist who entered the data for the treatment plan had failed to enter the proper dose per fraction after applying a dose optimization plan. Nor was the error caught during a routine review of the plan by the treatment team prior to loading the plan from the planning system. The confusion may have arisen from the fact that this was the first multi-fractionated treatment that the dosimetrist had prepared as all previous treatments they had been involved with were all single fractions.

"Due to the nature of this event it will be reported to the U.S. Nuclear Regulatory Commission Operations Center. The licensee is aware of the requirement to file a written report within the next 15 days. This item will remain open an under investigation until receipt of that report.

"Corrective Actions:
1 New procedure written
2 Personnel received additional training"

The patient has been informed of the incident and has re-commenced radiation treatment.

The state has no follow-up intentions for this event.

Illinois event number: IL070062

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

* * *UPDATE BY FSME (FLANNERY) TO KOZAL AT 0950 ON 11/27/07* * *

"This event (EN43805) has been reviewed and determined to be a reportable medical event."

AGREEMENT STATE REPORT - MEDICAL DOSE TO WRONG ORGANS

The Agreement State of Louisiana submitted the following information:

"On Monday November 19, 2007, Cardinal Health Nuclear Pharmacy delivered an isotope dose labeled incorrectly. The dose delivered, was labeled Tc-99m Mertiatide (Mag-3) assayed at 5.1 milliCuries at 9:13 AM. The dose ordered was for a Renal Scan scheduled for 9:30 AM. After injection of the ordered dose, subsequent imaging revealed accumulation of radiopharmaceutical in the liver and spleen. The target organ for Mag-3 is the kidneys. The images would suggest Tc-99m Sulfur Colloid as the agent delivered. This information was reported by the facility that received the dose. The facility also notified Cardinal Health.

"This matter is under investigation by Louisiana DEQ."

This report refers to Louisiana event identification number: LA070030.

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.