Event Notification Report for March 27, 2009
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/26/2009 - 03/27/2009
Hospital
Event Number: 44941
Rep Org: MEDICAL PHYSICS CONSULTANTS
Licensee: REGIONAL MEDICAL IMAGING - FLINT
Region: 3
City: FLINT State: MI
County:
License #: 21-26076-01
Agreement: N
Docket:
NRC Notified By: LAURA LUNA
HQ OPS Officer: PETE SNYDER
Licensee: REGIONAL MEDICAL IMAGING - FLINT
Region: 3
City: FLINT State: MI
County:
License #: 21-26076-01
Agreement: N
Docket:
NRC Notified By: LAURA LUNA
HQ OPS Officer: PETE SNYDER
Notification Date: 03/27/2009
Notification Time: 12:30 [ET]
Event Date: 03/27/2009
Event Time: 00:00 [EDT]
Last Update Date: 03/27/2009
Notification Time: 12:30 [ET]
Event Date: 03/27/2009
Event Time: 00:00 [EDT]
Last Update Date: 03/27/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
HIRONORI PETERSON (R3)
ANGELA MCINTOSH (FSME)
HIRONORI PETERSON (R3)
ANGELA MCINTOSH (FSME)
MISSED CONFIRMATIONS LED TO PATIENT RECEIVING A HIGHER DOSE
A patient was prescribed a 12 millicurie dose of I-131 for treatment. When the hospital requested the dose from the pharmacy, a 15 millicurie dose was mistakenly requested. The dose requested was not confirmed against the prescribed dose.
When the patient came in for treatment, the technologist preparing the dose measured a 15.5 millicurie dose but did not realize or confirm that this dose differed from the 12 millicurie prescribed dose. The 15.5 millicurie dose was administered instead of a 12 millicurie dose resulting in a dose to the patient of more than a 20% difference from the prescribed dose. The licensee will inform the patient of the higher dose.
To prevent this same type of incident from happening in the future the hospital plans on changing current practice to confirm two different times that the prescribed dose and the requested dose from the pharmacy are the same.
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 was prescribed a 12 millicurie dose of I-131 for treatment. When the hospital requested the dose from the pharmacy, a 15 millicurie dose was mistakenly requested. The dose requested was not confirmed against the prescribed dose.
When the patient came in for treatment, the technologist preparing the dose measured a 15.5 millicurie dose but did not realize or confirm that this dose differed from the 12 millicurie prescribed dose. The 15.5 millicurie dose was administered instead of a 12 millicurie dose resulting in a dose to the patient of more than a 20% difference from the prescribed dose. The licensee will inform the patient of the higher dose.
To prevent this same type of incident from happening in the future the hospital plans on changing current practice to confirm two different times that the prescribed dose and the requested dose from the pharmacy are the same.
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: 44937
Facility: COOPER
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: EDWARD McCUTCHEN JR.
HQ OPS Officer: MARK ABRAMOVITZ
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: EDWARD McCUTCHEN JR.
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/26/2009
Notification Time: 18:52 [ET]
Event Date: 03/27/2009
Event Time: 00:00 [CDT]
Last Update Date: 04/08/2009
Notification Time: 18:52 [ET]
Event Date: 03/27/2009
Event Time: 00:00 [CDT]
Last Update Date: 04/08/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
NEIL OKEEFE (R4)
NEIL OKEEFE (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
TROUBLESHOOTING EMERGENCY OFFSITE FACILITY COMMUNICATIONS
"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) as an event that will result in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability (e.g. significant portion of control room indication, Emergency Notification System or offsite notification system.)
"At approximately 0000 on 3/27/09, all five of the T-1 data lines to the Emergency Offsite Facility (EOF) will be taken out of service to troubleshoot and repair malfunctioning phone company equipment. Multiple short duration outages will occur until the malfunction can be located and repaired. This outage will cause a loss of Plant Management Information System printer capability, Safety Parameter Display System (SPDS) capability, FTS 2001 system, Alternate Intercom system, Low Band base radio (the primary Downwind Survey team radio), State Notification Telephone System, Dose Assessment and some external phone lines at the EOF. This loss of capability affects only the off-site EOF. All other emergency communications from the site to the NRC are not affected.
"Compensatory measures being put into effect include SPDS information relayed via telephone from the Technical Support Center, dose assessment and offsite notifications and reports via alternate means, or relocate the on-call Emergency Director to the Control Room and make notifications to offsite agencies via the Control Room Communicator. CNS is in contact with communications personnel to restore the T-1 lines as quickly as possible in the event of a declared emergency.
"Region IV and the NRC Resident Inspector were notified of the planned loss of the T-1 lines. CNS will notify the NRC when all EOF equipment affected by the T-1 lines have been satisfactorily tested and verified to be operational."
* * * UPDATE ON 3/27/09 AT 1405 FROM STEVE WHEELER TO MARK ABRAMOVITZ * * *
"This notification is an update to EN#44937 regarding the planned troubleshooting of Emergency Off Site Facility (EOF) communications equipment. Discussion with the NPPD telecommunications vendor have identified that the planned troubleshooting and repair of Cooper's EOF communications equipment was completed non-intrusively. There was no actual interruption of the EOF communications equipment. Testing by the vendor, NPPD Telecommunications Department personnel and NPPD Emergency Preparedness Department personnel has been completed and all EOF communications equipment has been verified to be fully functional. The NRC Senior Resident Inspector and the State and Local Agencies will be notified that the CNS EOF communications equipment is fully functional."
Notified the R4DO (O'Keefe).
* * * UPDATE AT 1739 EDT ON 3/30/09 FROM ED MCCUTCHEN TO JOE O'HARA * * *
"This notification is a second follow up to Event Notification EN# 44937 of 3/26/09 at 1852 EDT which reported the planned troubleshooting of Emergency Off Site Facility (EOF) communications equipment. The first follow up reported that the planned troubleshooting was completed non-intrusively and that no actual interruption of EOF capability occurred.
"Subsequently the telecommunication provider has advised that further troubleshooting is required. Therefore, at approximately 2300 on 3/30/09, all five T-1 data lines to the EOF will be taken out of service to troubleshoot and repair malfunctioning phone company equipment. Multiple short duration outages will occur until the malfunction can be located and repaired. This outage will cause a loss of Plant Management Information System printer capability, Safety Parameter Display System (SPDS) capability, FTS 2001 system, Alternate Intercom system, Low Band base radio (the primary Downwind Survey team radio), State Notification Telephone System, Dose Assessment and some external phone lines at the EOF. This loss of capability affects only the off-site EOF. All other emergency communications from the site to the NRC are not affected.
"Compensatory measures being put into effect include SPDS information relayed via telephone from the Technical Support Center, dose assessment and offsite notifications and reports via alternate means, or relocate the on-call Emergency Director to the Control Room and make notifications to offsite agencies via the Control Room Communicator. CNS is in contact with communications personnel to restore the T-1 lines as quickly as possible in the event of a declared emergency.
"Region IV and the NRC Resident Inspector were notified of the planned loss of the T-1 lines. CNS will notify the NRC when all EOF equipment affected by the T-1 lines have been satisfactorily tested and verified to be operational."
Notified R4DO(Deese).
* * * UPDATE AT 0840 EDT ON 3/31/09 FROM ROY GILES TO DONALD NORWOOD * * *
"Third follow-up of event notification EN #44937.
"Discussions with the NPPD telecommunications vendor have identified that troubleshooting and repairs to the EOF communications equipment are complete [as of 0639 CDT]. Post-work testing by Telecommunications Department personnel and NPPD Emergency Preparedness Department personnel has been completed and all EOF communications equipment has been verified to be fully functional. The NRC Senior Resident Inspector will be informed."
Notified R4DO (Deese).
* * * UPDATE FROM ED MCCUTCHEN TO JOE O'HARA AT 1425 EDT ON 4/7/09 * * *
"This notification is a fourth follow up to Event Notification EN# 44937 of 3/26/09 at 1852 EDT which reported the planned troubleshooting of Emergency Off Site Facility (EOF) communications equipment. The third follow up reported that subsequent repairs were completed and that EOF full communication capability had been restored.
"Since then, the telecommunication provider has advised that more troubleshooting is required. Therefore, at approximately 2300 on 4/7/09, all five T-1 data lines to the EOF will again be taken out of service to troubleshoot and repair malfunctioning phone company equipment. Multiple short duration outages will occur for approximately 7 hours until the malfunction can be located and repaired. This outage will cause a loss of Plant Management Information System printer capability, Safety Parameter Display System (SPDS) capability, FTS 2001 system, Alternate Intercom system, Low Band base radio (the primary Downwind Survey team radio), State Notification Telephone System, Dose Assessment and some external phone lines at the EOF. This loss of capability affects only the off-site EOF. All other emergency communications from the site to the NRC are not affected.
"Compensatory measures being put into effect include SPDS information relayed via telephone from the Technical Support Center, dose Assessment and offsite notifications and reports via alternate means, or relocate the on-call Emergency Director to the Control Room and make notifications to offsite agencies via the Control Room Communicator. CNS is in contact with communications personnel to restore the T-1 lines as quickly as possible in the event of a declared emergency.
"Region IV and the NRC Resident Inspector were notified of the planned loss of the T-1 lines. CNS will notify the NRC when all EOF equipment affected by the T-1 lines have been satisfactorily tested and verified to be operational."
Notified R4DO(Spitzberg).
* * * UPDATE FROM CLYDE EDGINGTON TO JOE O'HARA AT 1443 EDT ON 4/8/09 * * *
"Discussions with the NPPD telecommunications vendor have identified that troubleshooting and repairs to the EOF communications equipment were not necessary and no work was performed. Post-work testing by Telecommunications Department personnel and NPPD Emergency Preparedness Department personnel has been completed and all EOF communications equipment has been verified to be fully functional.
The NRC Senior Resident Inspector has been informed.
Notified R4DO(B. Spitzberg)
"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) as an event that will result in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability (e.g. significant portion of control room indication, Emergency Notification System or offsite notification system.)
"At approximately 0000 on 3/27/09, all five of the T-1 data lines to the Emergency Offsite Facility (EOF) will be taken out of service to troubleshoot and repair malfunctioning phone company equipment. Multiple short duration outages will occur until the malfunction can be located and repaired. This outage will cause a loss of Plant Management Information System printer capability, Safety Parameter Display System (SPDS) capability, FTS 2001 system, Alternate Intercom system, Low Band base radio (the primary Downwind Survey team radio), State Notification Telephone System, Dose Assessment and some external phone lines at the EOF. This loss of capability affects only the off-site EOF. All other emergency communications from the site to the NRC are not affected.
"Compensatory measures being put into effect include SPDS information relayed via telephone from the Technical Support Center, dose assessment and offsite notifications and reports via alternate means, or relocate the on-call Emergency Director to the Control Room and make notifications to offsite agencies via the Control Room Communicator. CNS is in contact with communications personnel to restore the T-1 lines as quickly as possible in the event of a declared emergency.
"Region IV and the NRC Resident Inspector were notified of the planned loss of the T-1 lines. CNS will notify the NRC when all EOF equipment affected by the T-1 lines have been satisfactorily tested and verified to be operational."
* * * UPDATE ON 3/27/09 AT 1405 FROM STEVE WHEELER TO MARK ABRAMOVITZ * * *
"This notification is an update to EN#44937 regarding the planned troubleshooting of Emergency Off Site Facility (EOF) communications equipment. Discussion with the NPPD telecommunications vendor have identified that the planned troubleshooting and repair of Cooper's EOF communications equipment was completed non-intrusively. There was no actual interruption of the EOF communications equipment. Testing by the vendor, NPPD Telecommunications Department personnel and NPPD Emergency Preparedness Department personnel has been completed and all EOF communications equipment has been verified to be fully functional. The NRC Senior Resident Inspector and the State and Local Agencies will be notified that the CNS EOF communications equipment is fully functional."
Notified the R4DO (O'Keefe).
* * * UPDATE AT 1739 EDT ON 3/30/09 FROM ED MCCUTCHEN TO JOE O'HARA * * *
"This notification is a second follow up to Event Notification EN# 44937 of 3/26/09 at 1852 EDT which reported the planned troubleshooting of Emergency Off Site Facility (EOF) communications equipment. The first follow up reported that the planned troubleshooting was completed non-intrusively and that no actual interruption of EOF capability occurred.
"Subsequently the telecommunication provider has advised that further troubleshooting is required. Therefore, at approximately 2300 on 3/30/09, all five T-1 data lines to the EOF will be taken out of service to troubleshoot and repair malfunctioning phone company equipment. Multiple short duration outages will occur until the malfunction can be located and repaired. This outage will cause a loss of Plant Management Information System printer capability, Safety Parameter Display System (SPDS) capability, FTS 2001 system, Alternate Intercom system, Low Band base radio (the primary Downwind Survey team radio), State Notification Telephone System, Dose Assessment and some external phone lines at the EOF. This loss of capability affects only the off-site EOF. All other emergency communications from the site to the NRC are not affected.
"Compensatory measures being put into effect include SPDS information relayed via telephone from the Technical Support Center, dose assessment and offsite notifications and reports via alternate means, or relocate the on-call Emergency Director to the Control Room and make notifications to offsite agencies via the Control Room Communicator. CNS is in contact with communications personnel to restore the T-1 lines as quickly as possible in the event of a declared emergency.
"Region IV and the NRC Resident Inspector were notified of the planned loss of the T-1 lines. CNS will notify the NRC when all EOF equipment affected by the T-1 lines have been satisfactorily tested and verified to be operational."
Notified R4DO(Deese).
* * * UPDATE AT 0840 EDT ON 3/31/09 FROM ROY GILES TO DONALD NORWOOD * * *
"Third follow-up of event notification EN #44937.
"Discussions with the NPPD telecommunications vendor have identified that troubleshooting and repairs to the EOF communications equipment are complete [as of 0639 CDT]. Post-work testing by Telecommunications Department personnel and NPPD Emergency Preparedness Department personnel has been completed and all EOF communications equipment has been verified to be fully functional. The NRC Senior Resident Inspector will be informed."
Notified R4DO (Deese).
* * * UPDATE FROM ED MCCUTCHEN TO JOE O'HARA AT 1425 EDT ON 4/7/09 * * *
"This notification is a fourth follow up to Event Notification EN# 44937 of 3/26/09 at 1852 EDT which reported the planned troubleshooting of Emergency Off Site Facility (EOF) communications equipment. The third follow up reported that subsequent repairs were completed and that EOF full communication capability had been restored.
"Since then, the telecommunication provider has advised that more troubleshooting is required. Therefore, at approximately 2300 on 4/7/09, all five T-1 data lines to the EOF will again be taken out of service to troubleshoot and repair malfunctioning phone company equipment. Multiple short duration outages will occur for approximately 7 hours until the malfunction can be located and repaired. This outage will cause a loss of Plant Management Information System printer capability, Safety Parameter Display System (SPDS) capability, FTS 2001 system, Alternate Intercom system, Low Band base radio (the primary Downwind Survey team radio), State Notification Telephone System, Dose Assessment and some external phone lines at the EOF. This loss of capability affects only the off-site EOF. All other emergency communications from the site to the NRC are not affected.
"Compensatory measures being put into effect include SPDS information relayed via telephone from the Technical Support Center, dose Assessment and offsite notifications and reports via alternate means, or relocate the on-call Emergency Director to the Control Room and make notifications to offsite agencies via the Control Room Communicator. CNS is in contact with communications personnel to restore the T-1 lines as quickly as possible in the event of a declared emergency.
"Region IV and the NRC Resident Inspector were notified of the planned loss of the T-1 lines. CNS will notify the NRC when all EOF equipment affected by the T-1 lines have been satisfactorily tested and verified to be operational."
Notified R4DO(Spitzberg).
* * * UPDATE FROM CLYDE EDGINGTON TO JOE O'HARA AT 1443 EDT ON 4/8/09 * * *
"Discussions with the NPPD telecommunications vendor have identified that troubleshooting and repairs to the EOF communications equipment were not necessary and no work was performed. Post-work testing by Telecommunications Department personnel and NPPD Emergency Preparedness Department personnel has been completed and all EOF communications equipment has been verified to be fully functional.
The NRC Senior Resident Inspector has been informed.
Notified R4DO(B. Spitzberg)