Event Notification Report for April 16, 2008
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/15/2008 - 04/16/2008
General Information or Other
Event Number: 44143
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: OKLAHOMA STATE UNIVERSITY MEDICAL CENTER
Region: 4
City: TULSA State: OK
County:
License #: OK-05860-01
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: JOHN KNOKE
Licensee: OKLAHOMA STATE UNIVERSITY MEDICAL CENTER
Region: 4
City: TULSA State: OK
County:
License #: OK-05860-01
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/16/2008
Notification Time: 16:35 [ET]
Event Date: 04/16/2008
Event Time: 14:00 [CDT]
Last Update Date: 04/17/2008
Notification Time: 16:35 [ET]
Event Date: 04/16/2008
Event Time: 14:00 [CDT]
Last Update Date: 04/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JEFFREY CLARK (R4)
BILL VON TILL (FSME)
JEFFREY CLARK (R4)
BILL VON TILL (FSME)
AGREEMENT STATE REPORT - MEDICAL EVENT
A patient at the Oklahoma State University Medical Center in Tulsa, Oklahoma was undergoing prostate treatment. The treatment was to implant 187 Pd-103 seeds (1.5 microCuries each) into the patient. The seeds were injected using a MIC gun which was manufactured by TheraGenics in Buford, Georgia. During the procedure it was observed that one of the seeds was sheared off with only 5% of the seed showing. The patient is believed to have the other 95% of the open seed inside his body. The radiation oncologist was present when this event happened. The patient was surveyed and his radiation levels were 0.46 mr/hr, which is within normal levels. The patient was not informed as yet, but should be by the attending physician. The half life of Pd-103 is 17 days, and most likely will be defused throughout the body.
* * * UPDATE ON 4/17/2008 AT 1036 FROM MIKE BRODERICK TO MARK ABRAMOVITZ * * *
The State provided the following information via email:
"At about 2:00 PM on April 16, a patient was receiving 187 Pd-103 seeds for prostate therapy. The seeds were Theragen Model 200 of 1.5 microCuries each, manufactured by Theragenics, in Buford, Georgia, and purchased from Bard in Georgia. After injecting the seeds, the facility discovered one end of a Pd-103 seed in the 'mic' cartridge that had been used to hold the seeds. Only about 5% of the seed was present, and it is assumed the other 95% was injected into the patient. The piece found was leaking radioactivity. Surveys with a calibrated meter showed that the patient met the criteria for unrestricted release. The licensee plans to ask the referring physician to notify the patient. The licensee speculates that a malfunction in the mic gun caused the seed to be out of alignment when the cartridge was inserted or removed, leading to the clipping of the end, but this is highly preliminary, and the result of speculation rather than definite findings. The licensee will do an investigation. The licensee has temporarily stopped doing prostate implants. DEQ will send investigators to the site."
Notified FSME (Burgess) and the R4DO (Clark).
* * * UPDATE ON 4/17/2008 AT 1536 FROM MIKE BRODERICK TO JASON KOZAL * * *
The State provided the following information via email:
"There was a miscommunication between the state and the facilities, average strength for the Pd-103 sources involved in this event is 1.5 milliCuries, rather than 1.5 microCuries. The licensee has informed the patient of the event. The mic gun involved has been taken out of service. It is also considered possible the cartridge holding the sources was flawed, but the cartridges were disposed of as biomedical waste immediately after the surgery and will not be available to be checked. The licensee informs [the state] that the cartridges are generally covered in blood after one of these procedures, and such cartridge disposal is typical. The licensees are holding the mic gun until a state inspector arrives for an investigation, after which it will be returned to the manufacturer for evaluation."
Notified FSME (Von Till) and R4DO (Miller).
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.
A patient at the Oklahoma State University Medical Center in Tulsa, Oklahoma was undergoing prostate treatment. The treatment was to implant 187 Pd-103 seeds (1.5 microCuries each) into the patient. The seeds were injected using a MIC gun which was manufactured by TheraGenics in Buford, Georgia. During the procedure it was observed that one of the seeds was sheared off with only 5% of the seed showing. The patient is believed to have the other 95% of the open seed inside his body. The radiation oncologist was present when this event happened. The patient was surveyed and his radiation levels were 0.46 mr/hr, which is within normal levels. The patient was not informed as yet, but should be by the attending physician. The half life of Pd-103 is 17 days, and most likely will be defused throughout the body.
* * * UPDATE ON 4/17/2008 AT 1036 FROM MIKE BRODERICK TO MARK ABRAMOVITZ * * *
The State provided the following information via email:
"At about 2:00 PM on April 16, a patient was receiving 187 Pd-103 seeds for prostate therapy. The seeds were Theragen Model 200 of 1.5 microCuries each, manufactured by Theragenics, in Buford, Georgia, and purchased from Bard in Georgia. After injecting the seeds, the facility discovered one end of a Pd-103 seed in the 'mic' cartridge that had been used to hold the seeds. Only about 5% of the seed was present, and it is assumed the other 95% was injected into the patient. The piece found was leaking radioactivity. Surveys with a calibrated meter showed that the patient met the criteria for unrestricted release. The licensee plans to ask the referring physician to notify the patient. The licensee speculates that a malfunction in the mic gun caused the seed to be out of alignment when the cartridge was inserted or removed, leading to the clipping of the end, but this is highly preliminary, and the result of speculation rather than definite findings. The licensee will do an investigation. The licensee has temporarily stopped doing prostate implants. DEQ will send investigators to the site."
Notified FSME (Burgess) and the R4DO (Clark).
* * * UPDATE ON 4/17/2008 AT 1536 FROM MIKE BRODERICK TO JASON KOZAL * * *
The State provided the following information via email:
"There was a miscommunication between the state and the facilities, average strength for the Pd-103 sources involved in this event is 1.5 milliCuries, rather than 1.5 microCuries. The licensee has informed the patient of the event. The mic gun involved has been taken out of service. It is also considered possible the cartridge holding the sources was flawed, but the cartridges were disposed of as biomedical waste immediately after the surgery and will not be available to be checked. The licensee informs [the state] that the cartridges are generally covered in blood after one of these procedures, and such cartridge disposal is typical. The licensees are holding the mic gun until a state inspector arrives for an investigation, after which it will be returned to the manufacturer for evaluation."
Notified FSME (Von Till) and R4DO (Miller).
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.
Power Reactor
Event Number: 44144
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: TIM BUNKELMAN
HQ OPS Officer: PETE SNYDER
Region: 3 State: WI
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: TIM BUNKELMAN
HQ OPS Officer: PETE SNYDER
Notification Date: 04/16/2008
Notification Time: 18:08 [ET]
Event Date: 04/16/2008
Event Time: 14:26 [CDT]
Last Update Date: 04/16/2008
Notification Time: 18:08 [ET]
Event Date: 04/16/2008
Event Time: 14:26 [CDT]
Last Update Date: 04/16/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
LAURA KOZAK (R3)
LAURA KOZAK (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
TWO GALLONS OF RADIOACTIVE WATER SPILLED IN PROTECTED AREA
"A small quantity of radioactive water spilled on the concrete in the Protected Area and is in the process of being cleaned up. Approximately two gallons of water leaked from a shipping container being moved from Containment. The water was contained to the local concrete and tractor trailer receiving the load. The tractor trailer remains in the Protected Area and will be processed for free release. Initial analysis shows the presence of Co-58, Mn-54, Co-60, and Cs-137. Specific activity levels are not available at this time. No individual contaminations occurred during this event.
"The licensee has reported this event to the Wisconsin Department of Natural Resources (WDNR) pursuant to WDNR Regulation NR706.03 at 1426 CDT. Subsequent review has determined that this event was not reportable to the WDNR and an update was provided to the WDNR at 1800 CDT.
"This event is reportable under 10 CFR 50.72 (b)(2)(xi), 'Any event or situation, related to the health and safety of the public or on-site personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made.'"
The Licensee notified the NRC Resident Inspector.
"A small quantity of radioactive water spilled on the concrete in the Protected Area and is in the process of being cleaned up. Approximately two gallons of water leaked from a shipping container being moved from Containment. The water was contained to the local concrete and tractor trailer receiving the load. The tractor trailer remains in the Protected Area and will be processed for free release. Initial analysis shows the presence of Co-58, Mn-54, Co-60, and Cs-137. Specific activity levels are not available at this time. No individual contaminations occurred during this event.
"The licensee has reported this event to the Wisconsin Department of Natural Resources (WDNR) pursuant to WDNR Regulation NR706.03 at 1426 CDT. Subsequent review has determined that this event was not reportable to the WDNR and an update was provided to the WDNR at 1800 CDT.
"This event is reportable under 10 CFR 50.72 (b)(2)(xi), 'Any event or situation, related to the health and safety of the public or on-site personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made.'"
The Licensee notified the NRC Resident Inspector.